Practising ignorance – exercising restraint

“…ignorance, allied with power, is the most ferocious enemy justice can have”. James Baldwin (1972)

The online Cambridge Dictionary records that the word ‘ignorant’ signifies not having enough knowledge, understanding, or information about something – and the online Collins English Dictionary adds the nuance that when we describe someone as ignorant, we mean that they do not know things which they should know.

I think I may therefore confidently echo James Baldwin in suggesting that ‘ignorance, allied with power’ may be understood to be embodied in the priapic figure of our present Premier when, politicking around the Home Counties with Priti Patel recently (as is his chilling wont), he prescribed membership of “fluorescent-jacketed chain gangs visibly paying your debt to society” (Guardian 2021) for those convicted of ‘anti-social behaviour’ (no trace of irony there!).

In case this spot of racist dog-whistling was too shrill for human ears to detect, he also lit the gas on half a century of fraught community policing when, with his very next breath, he proclaimed that ‘stop and search’, that key instrument of racially-targeted State oppression in modern Britain, was “a kind and a loving thing to do”.

It’s always problematic engaging on any level with the proliferating populist poseurs that (over-)populate the public sphere in post-modernity. Best in some ways to let it all wash over us, pour ne pas encourager les autres. But I want to try to think and write in a clear-eyed way about ‘race’ and racism and I think that these prime ministerial pronouncements illuminate the mindset of a whole class. As it happens to be the ruling caste in this country, it’s worth paying attention. And because it is about ‘race’, silence from the likes of me very quickly tips over into collusion or endorsement.

In that press conference, chattel slavery in the American South of the seventeenth, eighteenth and nineteenth centuries – as particularly extended through to the present day by the American penal system (in which more African Americans are incarcerated, than there were slaves in the United States in 1850 (Resler, 2019)) – is an historical phenomenon that is being referenced, but its true nature, its continuation by other means, and the identity and mindset of its perpetrators is being actively ignored.

Our protagonist, therefore, is being ignorant in the most violent possible way. He is indeed a candidate, as Baldwin warned, to be “the most ferocious enemy justice can have”. Furthermore, as Baldwin had previously observed, “whatever white people do not know about Negroes reveals, precisely and inexorably, what they do not know about themselves” (Baldwin [1963] 2017, pp. 43-44).

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Because this particular paragon of our ruling ‘elite’ is such an admirer of Winston Churchill – that Colossus of Empire (in its (British) late period) and committed ideological adherent and proponent of racist imperialism, who in 1902 insisted that the “Aryan stock is bound to triumph” and in 1955 proposed “Keep England White” as the Conservative Party’s electoral slogan (and so who undoubtedly would have nodded his head at that ‘chain gang’ dog whistle) – it is with the figure of Churchill that we may as well begin.

In Pat Barker’s Regeneration trilogy (1998), reference is made (pp. 641-642) to an episode when Churchill was Home Secretary, in which he and his Parliamentary Private Secretary Edward Marsh “spent an entire afternoon beating each other’s buttocks with a plaited birch”. There had been debate whether official adoption of this newly designed implement amounted to cruelty and so Churchill and Marsh had ‘done their duty’ by testing its efficacy. They are supposed, in Barker’s retelling of the tale, to have drawn the conclusion that “they’d had worse beatings at school” (Churchill’s experiences of being caned at Harrow are well-documented; the incident with Marsh is mentioned in Hassall (1959); Churchill’s Parliamentary Private Secretary during World War Two, Brendan Bracken, set up his own secret summer school in the 1950s so that he could contrive to have himself regularly caned, in role as a 16 year old schoolboy who suffered from premature ageing).

Now, it is not my purpose here to practice ‘wild psycho-analysis’ at a distance, or to pry into private lives, even if some such details have come into the public domain; nor to be prurient or judgmental about sexual or sexualised practices in what were sexually repressive times. We might at most very gently and cautiously infer, at the human and individual level, that these are the survival strategies of tormented souls. Moreover, I too am a survivor of single-sex boarding schools: to declare an interest, and not to put myself above the fray. I too must atone for my own guilt by association with the racist ravages of Empire.

No: the context and rationale for having anything at all to say about the personal lives of such historical figures lies in their power and privilege in the public sphere and the relations of domination which they considered themselves entitled to pursue. What I want very simply to notice for now are two particular phenomena: the first of which is the pervasive quality and characteristic of cruelty – elevated almost to the status of a virtue, as in ‘it’s cruel to be kind’; ‘it will make a man of you’; and other more or less insidious bromides and banalities of that ilk.

(‘I went through it, and it didn’t do me any harm’ is another one of these sayings, and it reminds me that at the boarding school in which I was deposited, I was a member of the first intake after the practice of being required to act as personal servant to the older pupils had been abolished. This was certainly a matter of personal relief to me; and it also meant that I bore witness to the disappointment of those who arrived in the four years before me, who had the practice passed on down to them, but couldn’t ‘make it alright’ by passing it further on down the line (and therefore had to find other less structured ways and means to assert dominance).)

The second phenomenon I want to foreground is the practice and exercise of restraint.

I have in mind to make full use of the double meaning of this word. It was essential in these disciplinary institutions that one took one’s beating (from housemasters or from older ‘fellow’-pupils) with a ‘stiff upper lip’: one did not ‘blub’; cruelty was something to be bitten back and doubled down on. This is not self-restraint in the sense of that conventional social virtue associated with the Aristotelian ‘Golden Mean’. This is systematic ‘control and restraint’, deployed ruthlessly against the creative spontaneity of the self, in order to suppress any upsurge of human emotion and cut it off at the source.

The Duke of Wellington famously claimed, on behalf of his officer classes, that the battle of Waterloo was won on the playing fields of Eton. His rank and file (those who survived) might have begged to differ. But we could perhaps argue that the great prizes of Victorian Empire – the power and reach of British dominion between the moment of Louis-Napoléon Bonaparte’s coup d’état in Paris in December 1851 and Gavrilo Princip’s two well-aimed pistol shots in Sarajevo in June 1914 – were won behind closed doors, in places and spaces dedicated to ritual humiliation. Generation upon cold, repressed, brutalized generation were sent away by their parents to be restrained in disciplinary institutions where they learned to exercise (self-)restraint when cruelties were administered to self or other; thus were they ‘trained for Empire’ and then sent out from these schools, and these shores, to rule over their fellow human beings, for whom they had no fellow feeling (were perhaps not capable of entertaining such fellow feeling).

The ideology of Free Trade presented them with an overriding mission to profiteer and to plunder; the ideology of racism allowed them to consider that their subjects were not human beings at all; and the ideology of Christianity (as opposed to the teachings of Jesus) provided the figleaf of the ‘civilising’ project, to still any lingering qualms.

This was the Rule of Britannia.

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Toni Morrison wrote about chain gangs and restraint in Beloved (1997): her furious, anguished, transcendental account of the trauma and the ghosts of slavery. A ‘chain gang’ (so ignorantly referenced in that prime ministerial photo opportunity), in the world of Beloved (pp. 125-130), means forty-six Black men caged in boxes like kennels or coffins (except that both dogs and the dead are housed in greater decency and comfort); the boxes lined up in a ditch dug five feet deep, five feet wide. Woken each morning to gunshots; uncaged and forced to pass a thousand foot of chain onward to each other through their ankle irons; forced to submit to sexual abuse from the guards before being marched to their long day’s sledgehammer toil in the quarry; sleeping, if sleep be found, in mud and floodwater, waiting for the bite of the cottonmouth.

This compass of cruelty beyond measure or comprehension is not literally what is being proposed today as Conservative policy; but it is what is being referenced. In case you doubt me, one notorious and flatly despicable scribe writing in The Sun (I won’t give him the recognition of an actual reference) in the immediate aftermath of that dog whistle suggested that these new ‘chain gangs’ in their new yellow jackets should be made to sing ‘Negro spirituals’: so that passers-by would be sure they were ‘wrong ‘uns’, as they scrubbed graffiti off of walls or picked up litter off of grass verges.

To be very explicit: this extreme of cruelty and intensity of white supremacist ideology is being referenced because our ruling ‘elite’ have a notion that there are enough nodding Churchills among us who find the references congruent with their innermost feelings. They calculate that it is worth being referenced. They’re not just chatting around the dinner table as the port is passed (in such conversations, subliminal referencing and sly dog whistling aren’t felt to be needed and more open language is used). They’re speaking to us this way because experience tells them that there’s votes and funding in it for them.

Have these pontificators and provocateurs read Beloved? The question is irrelevant. They are ignorant, because they elect not to integrate the knowledge, the awareness, and the shame that is present and inherent in the history.

If any of them have read that book, they will also have encountered what Morrison writes about the ‘bit’ or ‘iron-bit’ or ‘face iron’. In her story, the character Paul D., who has escaped that Georgia chain gang described above, is reluctantly disclosing to Sethe, his host (whom he knew from ‘Sweet Home’, an earlier and relatively less troubled period of captivity) some of what he has endured. Sethe asks him why he didn’t say anything at a particular juncture in the story and Paul D. tells her that he had the ‘bit’ on him – and therefore he was physically unable to speak:

“he wants me to ask him about what it was like for him, about how offended the tongue is, held down by iron, how the need to spit is so deep you cry for it.  She already knew about it, had seen it time after time in the place before Sweet Home. Men, boys, little girls, women. The wildness that shot up into the eye the moment the lips were yanked back.” (1997, p. 84)

This practice is also briefly depicted in episode three of the recent television adaptation of Colson Whitehead’s Underground Railroad (2017). However, Irina Popescu (2017) explains that contemporary research into slavery, restraint and torture has uncovered very little information on the iron bit. She hypothesizes that “this suggests that its physical representation and implementation remains locked away in the realm of the unimaginable”. She continues:

“Some human bits covered the entire mouth, neck, and nose, leaving the eyes unfettered so the slave could continue to see and thus proceed with his or her work. In this sense, the bit initially prevented speech by covering the mouth. After the bit was removed, the mouth was so dehydrated that the victims found themselves too hoarse to form words. (ibid.)”

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James Baldwin once wrote: “For the horrors of the American Negro’s life there has been almost no language” ([1963] 2017, p. 62); and I must at once concede that at this point I don’t know what to write. I don’t know whether I can, or should, write anything at all. It may well be that my complicity disqualifies me, white middle-class male of a certain age that I am. I do know for certain that I can add nothing to what Toni Morrison has written. Here is unspeakability; unthinkability; unimaginability.

And yet: I perceive that it demands to be known. No – let me not hide behind the passive voice. Let me say rather that ‘it’ (the unspeakability, the unthinkability, the unimaginability of restraining human beings in chattel slavery) demands of me that I know it: that I not practice ignorance in the face of it; that I not stifle or suppress it, nor leave it lying in the shadows of consciousness, a ‘subjugated knowledge’ (Foucault 1976). I also think this is what Paul Gilroy is getting at when he writes of ‘imaginative proximity to terror’ (although that would be Baldwin’s or Morrison’s, not mine to claim) and says that “though they were unspeakable, these terrors were not inexpressible” (Gilroy 1993, p. 73).

Restraint. Control. Mild, measured, moderate-sounding words. A clinical tone, when coupled together – ‘control and restraint’ – the ‘and’ forging a collocation, a connection, like a link of chain. Makes eminent, self-evident sense, on the face of it, no?

But now let’s review some more recent history. Here are the deaths of six Black men; five of these deaths taking place in the UK, the sixth in the USA. There isn’t space here to do justice either to their lives or to the manner of their deaths; however, what links them, apart from the social constructs of ‘race’ and gender, is the fact that all six of them died of asphyxiation and/or cardiac arrest as a result of being restrained by agents of State. Three of these men at least – the first and the last two – found breath, during the restraint, sufficient to be able to say, to those agents of State, “I can’t breathe”.

David Bennett died during a nursing restraint on 30 October 1998 at the Norvic Clinic, a Medium Secure Unit in Norwich in which he had been for many years, off and on, a patient. Bennett wrote a letter to the Head of Nursing Services in 1993, on a previous admission, observing that “there are over half a dozen black boys in this clinic. I don’t know if you have realized that there are no Africans on your staff at the moment. We feel there should be at least two black persons in the medical or social work staff. For the obvious reasons of security and contentment for all concerned please do your best to remedy this appalling situation” (Independent Inquiry 2003, p. 9). On the evening of his fatal restraint following a violent disturbance on the ward, Bennett was heard saying to the nursing team “Get off me, get off me, I can’t breathe. Get off my throat” (Independent Inquiry 2003, p. 21).

In January 1999, Roger Sylvester died under police restraint in Haringay, London. The report of the inquest (Guardian 2003) relates that Sylvester:

“stopped breathing at the emergency psychiatric unit at St Anne’s hospital, Haringey, when six police officers held him down on the floor for about 20 minutes, St Pancras coroner’s court heard. He fell into a coma and died later at the Whittington hospital, north London. The court had heard that dangerous and unreasonable force was used and Mr Sylvester was handcuffed and sometimes restrained on his stomach.”

On 21 August 2008, Sean Rigg died of cardiac arrest and partial positional asphyxia under police restraint in Brixton, London. The Wikipedia summary of the circumstances of his death record that Rigg was chased by four police officers and

“was handcuffed and restrained in a prone, face down position as officers leant on him for eight minutes. Arrested for assaulting a police officer, public disorder and theft of a passport—which was actually his own—he was then placed face-down with his legs bent behind him in the caged rear section of a police van and transported to Brixton police station. During the journey “his mental and physical health deteriorated” and he was “extremely unwell and not fully conscious” when eventually taken out of the van. This followed a delay of ten minutes during which he was left handcuffed in a ‘rear stack’ position, unattended and unmonitored while the van sat outside the station in the car parking area.”

On 4 November 2013, Leon Briggs died under police restraint in Luton. According to a news report of the inquest (BBC 2021b):

The way police officers moved a restrained man who later died was “potentially dangerous” and against “strict guidance”, an inquest heard. Leon Briggs, 39, was restrained under the Mental Health Act on a street in Luton, handcuffed and placed in leg restraints on 4 November 2013. He was lifted face-down to a van and taken to Luton police station. He later became unconscious and died. An officer told the inquest carrying Mr Briggs face-down was “not ideal”.

The jury found that “there was a gross failure to provide Leon with basic medical attention and that there was a direct causal connection between this conduct and his death. They recorded a conclusion that his death was ‘contributed to by neglect’.”

We should pause here in the sequence to note that, in January 2017, the Angiolini Review report (commissioned by Theresa May) found that:

“57.  There is evidence of disproportionate deaths of BAME people in restraint related deaths. Any death involving a BAME victim who died following the use of force has the capacity to provoke community disquiet leading to a lack of public confidence and trust in the justice system. This can be exacerbated if people are not seen to be held to account, or if the misconduct process is opaque (Angiolini 2017, p. 15).”

Now we come to the fifth of these deaths: consider this BBC News report on the death of Kevin Clarke under police restraint in Lewisham, London in March 2018 (BBC 2021a):

“Mr Clarke had been lying on the ground and attempted to get to his knees before being restrained …. He was handcuffed and legs restraints were applied. Police body-worn video footage reveals Mr Clarke repeatedly told officers “I can’t breathe”, before being made to walk to an ambulance, still bound at the knees while barely conscious … .”

The final death in this sequence is perhaps the most well-known. On 25 May 2020, in Minneapolis, George Floyd was killed under police restraint. Here is the Wikipedia summary of witness accounts and video recordings taken at the scene:

“Floyd can be heard repeatedly saying “I can’t breathe”, “Please”, and “Mama”; Lane then asked for an ambulance for Floyd, “for one bleeding from the mouth”. Floyd repeated at least 16 times that he could not breathe. At one point a witness said: “You got him down. Let him breathe.” After Floyd said, “I’m about to die”, Chauvin told him to “relax”. An officer asked Floyd, “What do you want?”; Floyd answered, “Please, the knee in my neck, I can’t breathe.”

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James Baldwin (to which very great writer, we can never return too often) once wrote that “when a white man faces a black man, especially if the black man is helpless, terrible things are revealed” ([1963] 2017, p. 51). Derek Chauvin is now serving a 22.5 year sentence for second-degree murder. However, in the UK, it is a fact that:

“despite more than 1,700 deaths in police custody and following police contact since 1990 there has never been a successful prosecution of any police officer for murder or manslaughter (Coles 2021).”

192 of these deaths were of people racialized as BAME and this number (14%) reflects the overall population ratios in the UK as of 2011. However, BAME deaths in police custody involving restraint, use of force and mental health issues are in each category more than twice as likely compared to other deaths in custody. Coles, who is the Director of INQUEST, has also argued that “the disproportionality in the use of force against Black people adds to the irrefutable evidence of structural racism embedded in policing practices”.

A very recent United Nations Human Rights Commission report (United Nations 2021), commissioned in the wake of the murder of George Floyd, concludes:

“61. Behind today’s systemic racism, racial violence, dehumanization and exclusion, however, lies the lack of a formal acknowledgement of the responsibilities of States, institutions, religious groups, universities, business enterprises and individuals that engaged in or profited from, and that continue to profit from, the legacy of enslavement, the transatlantic trade in enslaved Africans and colonialism”

and calls on States Parties to the UNCHR to take action thus:

“68. Listening to the voices of people of African descent, the need for a global transformative agenda for racial justice and equality is clear. The four-point agenda in the annex sets out the key changes that are needed, which have also been elaborated in the present report under the subheadings on the way forward. Comprehensively implemented, the agenda would:

 (a) Reverse the cultures of denial, dismantle systemic racism and accelerate the pace of action;

 (b) End impunity for human rights violations by law enforcement officials and close trust deficits;

 (c) Ensure that the voices of people of African descent and those who stand up against racism are heard and that their concerns are acted upon;

 (d) Confront legacies, including through accountability and redress.”

Furthermore, the UN Special Rapporteur (United Nations 2017) has commanded States Parties to the UNCRPD (United Nations 2006) to desist from all coercive practices in psychiatry and this would include ‘control and restraint’. The importance and urgency of the challenge to the status quo upheld by the racist State, and to the range of practices by which that status quo is maintained, cannot be overstated.

I am conscious of not having said anything new here as such and I hope this piece reaches a readership who may instantly recognize just how far behind the curve I have been – and, likely enough, still am. But I want to say that I’m taking notice and that taking notice is, I believe and trust, a creative antidote to practicing ignorance. Those great lambasters of restraint of trade and mealy-mouthed objectors to restraint of press freedoms that have been governing this country since the days of Empire are pursuing the active continuation of the practices of restraining entailed in slavery and the toxic ooze of it seeps out through every membrane of the body politic. And I wonder what happens to a ruling class, to use that term, when in order to keep power it has to (officially) renounce the practice that brought it such unimaginable riches and yet corrupted it so completely? What happens when institutional approval and statutory sanction for the handing down and passing on of misery and cruelty is withheld? Perhaps practices of cruelty on such a scale must somehow persevere and find outlets for expression, because such drives can never be sublimated.

Racist dog whistles are not ‘merely’ racist dog whistles. They tell us that nothing – nothing whatsoever – has changed in the mindset. And this brings us back to the beginning of this blog, and the need to take our leave of the present monarch’s present First Minister (and let’s take every opportunity to remind ourselves that it was the Royal Family in this country (albeit in those days not the Windsors themselves, but the Stuarts) that formalized the transatlantic slave trade in the second half of the seventeenth century (hence the mind-boggling wealth now at the Windsors’ disposal)).

What, then, are we to make of the figure of the man whose remark apparently in passing set us off on such a journey? Perhaps the figure of Churchill may provide further illumination, if not the kind of light that anyone would much want shone…

For if associations to Churchill’s cane inexorably took us back to the ‘iron bit’, then associations to Churchill’s cigar lead inevitably to another pale, scruffy-blond-haired, ‘Aryan’, self-promoting, ‘Establishment’ (of the ‘in it yet not of it’ type), self-consciously ‘eccentric’, bonhomous, clowning, hob-nobbing, celebrity serial abuser; hiding in plain view, in the very apple of the public eye, on first-name terms with the world at large; impervious to questioning, immune to criticism; the full horror of his depradations and the full extent of the cover-up around him only emerging even partially into view after he had passed beyond reach of the law of this country, or indeed of any other earthly judgement….

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Racial abuse. Let’s renounce it in ourselves. Let’s call it out in others, whenever and wherever it rears its ugly, privileged, supremacist head. Let’s be going along with it not one second longer.

References

Angiolini, E. (2017) Report of the Independent Review of Deaths and Serious Incidents in Police Custody. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/655401/Report_of_Angiolini_Review_ISBN_Accessible.pdf

Baldwin, J. ([1963] 2017) The Fire Next Time. London: Penguin.

Baldwin, J. (1972) No Name in the Street. London: Vintage.

Barker, P. (1998) The Regeneration Trilogy. London: Penguin.

BBC (2021a) ‘Kevin Clarke: Met Police apologises over restraint death’. https://www.bbc.co.uk/news/uk-england-london-55694916

BBC (2021b) ‘Leon Briggs: Police and ambulance ‘failures’ in restraint death’. https://www.bbc.co.uk/news/uk-england-beds-bucks-herts-56339607

Coles, D. (2021) ‘Deaths in detention: Why aren’t we learning lessons from UK deaths in police custody?’ https://lacuna.org.uk/black-lives-matter/deaths-in-detention-why-arent-we-learning-lessons-from-uk-deaths-in-police-custody/

Foucault, M. (1976) ‘Two lectures’. Translated by A. Fontana and P. Pasquino. In Gordon, C. (ed.) (1980) Power/knowledge: Selected interviews and other writings 1972-1977. New York: Pantheon, pp. 78-108.

Gilroy, P. (1993) The Black Atlantic: Modernity and Double Consciousness. London: Verso.

Guardian (2003) ‘Detained man unlawfully killed by police’. https://www.theguardian.com/uk/2003/oct/03/ukcrime.prisonsandprobation

Guardian (2021) ‘Johnson proposes hi-vis chain gangs as part of crime plan’. https://www.theguardian.com/uk-news/2021/jul/27/johnson-proposes-hi-vis-chain-gangs-as-part-of-crime-plan

Hassall, C. (1959) Edward Marsh, Patron of the Arts: A Biography. London: Longmans.

Independent Inquiry into the Death of David Bennett (2003). http://image.guardian.co.uk/sys-files/Society/documents/2004/02/12/Bennett.pdf

Morrison, T. (1997) Beloved. London: Vintage.

Popescu, I. (2017) ‘Biting iron, forever smiling: the iron-bit, the wounded mouth, and un-silencing in Toni Morrison’s Beloved’. In A. Lobodziec and B.N. Fondo (eds) The Timeless Toni Morrison: The Past and The Present in Toni Morrison’s Fiction. A Tribute to Toni Morrison on Occasion of Her 85th Birthday. Oxford: Peter Lang. https://www.academia.edu/34936113/Biting_Iron_Forever_Smiling_the_Iron_Bit_the_Wounded_Mouth_and_Un_Silencing_in_Toni_Morrison_s_Beloved

Resler, M. (2019) ‘Systems of trauma: Racial trauma’. Issue brief. http://www.fact.virginia.gov/wp-content/uploads/2019/05/Racial-Trauma-Issue-Brief.pdf

United Nations (2006) Convention on the Rights of Persons with Disabilities https://www.un.org/development/desa/disabilities/convention-on-the-rights-of-persons-with-disabilities.html

United Nations (2017) Report of the Special Rapporteur on the Right of Everyone to the Enjoyment of the Highest Attainable Standard of Physical and Mental Health. UN General Assembly – A/HRC/35/21. https://documents-dds-ny.un.org/doc/UNDOC/GEN/G17/076/04/PDF/G1707604.pdf?OpenElement

United Nations (2021) Promotion and protection of the human rights and
fundamental freedoms of Africans and of people of African
descent against excessive use of force and other human rights
violations by law enforcement officers
. A/HRC/47/53.
Report of the United Nations High Commissioner for Human Rights. https://undocs.org/A/HRC/47/53

Whitehead, C. (2017) Underground Railroad. London: Fleet.

Janeway’s dilemma: coercive treatment and human rights in ‘eating disorders’ inpatient units

In 2017 the UN Human Rights Council published the “Report of the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health”. The secretariat prefaces the report by observing the Rapporteur’s call “for a shift in the paradigm, based on the recurrence of human rights violations in mental health settings, all too often affecting persons with intellectual, cognitive and psychosocial disabilities” (p.1).

The report goes on to say that “Informed consent is a core element of the right to health, both as a freedom and an integral safeguard to its enjoyment” (p.14). The right to consent to treatment includes the right to refuse treatment but “the proliferation of paternalistic mental health legislation and lack of alternatives has made medical coercion commonplace” (p.14). Justifications for using coercion based on risk and dangerousness and medical necessity are subjective and “exclusive to psychiatrists, who work in systems that lack the clinical tools to try non-coercive options” (p.14).

The report continues:

“Coercion in psychiatry perpetuates power imbalances in care relationships, causes mistrust, exacerbates stigma and discrimination and has made many turn away, fearful of seeking help within mainstream mental health services. Considering that the right to health is now understood within the framework of the Convention on the Rights of Persons with Disabilities [CRPD], immediate action is required to radically reduce medical coercion and facilitate the move towards an end to all forced psychiatric treatment and confinement. In that connection, States must not permit substitute decision-makers to provide consent on behalf of persons with disabilities on decisions that concern their physical or mental integrity; instead, support should be provided at all times for them to make decisions, including in emergency and crisis situations.” (p.15)

The report acknowledges the radical nature of these proposals and the concerns of stakeholders including medical practitioners and proceeds nonetheless to invite States to move towards an “absolute ban on all forms of non-consensual measures … Instead of using legal or ethical arguments to justify the status quo, concerted efforts are needed to abandon it. Failure to take immediate measures towards such a change is no longer acceptable” (p.15)

The implications of this report have been seized upon by service user and survivor groups (see for example Point 7 of the Executive Summary of the Kindred Minds BME Manifesto at https://www.nsun.org.uk/news/bme-mental-health-service-users-launch-manifesto) but mental health services are not perhaps falling over themselves in their haste to catch up.

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The reference to ‘psychosocial disabilities’ includes the contested diagnostic fields of ‘personality disorder’ and ‘eating disorder’ and my business in this blog is with the latter category. For more than fifteen years now I have been working as a psychotherapist on an inpatient ‘adult eating disorders’ unit and for the last seven or so of these years I’ve been leading the psychological therapies team there.

The ‘symptom’ being treated is starvation and the treatment being enforced is refeeding. Psychological therapies are understood to play a central role in supporting this process and/or in supporting the sufferer to undergo the intervention. In my role I am therefore unambiguously party to and implicated in this enforced treatment. This treatment is possibly often life-saving and life-restoring and yet is experienced as a terrifying intrusion, one to be resisted at times by any means possible, by many of the individuals who receive it – and now it has been proclaimed to be part of a widespread and endemic abuse of the human rights of those same individuals.

When I first arrived on that ward, more than fifteen years ago, coercive treatments under the Mental Health Act were very rare (I emphasise here that it is adults I am thinking of and the particular dynamics of adolescent units, although of course also covered by the Rapporteur’s findings, are outside my authority to comment upon). Adult patients in those days were on some psychological level ‘volunteering’ to undergo the intervention, in the hope of making a full medical recovery from malnutrition and from the distress that drove the troubled or troublesome food practices to begin with.

Nowadays 30-60% of patients at any one time are detained under MHA s.3 for compulsory treatment for their ‘disorder’ (specifically, anorexia nervosa, for other manifestations of eating distress are very rarely funded for this kind of unit). Coercion is therefore more explicitly medico-legal than it used to be, even though refeeding was always carried out across a power differential. And according to the Special Rapporteur, the coercive aspect of ‘eating disorder’ treatment is therefore more explicitly in contravention of international law.

In this blog I do not propose to argue for or against the findings and recommendations of the Special Rapporteur. I propose to treat them as a given and to look at the treatments I have been party to and the ethical issues they have always raised in this particular new light. Historic moments like the publication of the report to the Human Rights Council do and must give pause for thought and one question in particular has been niggling away at the back of my mind:

What can the fourth season of Star Trek: Voyager teach us about the ethical limits and excesses and the psychosocial dynamics of coercive treatment for ‘eating disorders’ on inpatient units?

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Well, I know you’ve been asking this very same question … and I don’t mean at all to be flippant about so deadly and deathly serious a subject. But sometimes material from literature and popular culture may serve as useful analogy or parable and I don’t want to blog about a ‘real life’ case study – for reasons I hope are self-evident.

So I hope you’ll bear with me, Trekkies and non-Trekkies alike, while we journey into the 24th century and the Delta Quadrant, 70,000 light years away from Earth, where we find the crew of the starship Voyager, under the command of the intrepid Captain Janeway, stranded far from home, making their way through unknown swathes of space and hostile predators, of whom the most significant for our purposes is The Borg, a hive of drone organisms who anthropophagically assimilate the technologies of alien species via enforced assimilation, turning enslaved individuals into cybernetically and surgically transformed fellow-drones within the Collective in pursuit of an idealised technological and socio-political perfection.

Now when I describe them thus, they don’t sound like a very sympathetic bunch, but you have to remember that the Borg drones have been subjected to coerced medical procedures in order to become Borg. They are already traumatised, colonised, subjected: made abject. They are victims-turned-predators, like a conscripted child army brainwashed into the massacre of alien villagers.

In their predatory and compassionless nature, they are very different indeed from the sufferers and survivors who pass through the door of the ward on which I work. But nonetheless I crave the reader’s indulgence not to be offended if I ask you (why? well, please bear with me a moment) to understand them not as the super-bad guys of the Star Trek mythology but as traumatised subjects with complex post-traumatic stress disorders; to imagine them as life forms with inalienable (although not conceptually individual) rights of their own – to see that they are fearfully perceived as ‘other’ in the sense of ‘belonging to an out-group’ – to see them as fiercely loyal to their sisterhood – in general to note that ‘their’ groupishness is different to ‘ours’ but that groupish they certainly are, chasing mirages of perfection together as one …

I ask you to allow, in short, for purposes of relating my parable, that this image might serve, in translation, as playful but respectful representation of the out-group in the Delta Quadrant of ‘severe and enduring’ eating distress …

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As our story begins, a drone has become isolated from the Borg Hive and taken into inpatient treatment in the Voyager Sickbay. The drone’s appellation is ‘Seven of Nine’. In our story there are no junior psychiatrists – but there is an Emergency Medical Hologram (EMH) (a long story!) and he is presenting a tricky case to the Captain/Consultant Janeway …

EMH: I’m afraid we have a decision to make. A difficult one. Her human immune system has reasserted itself with a vengeance. … Her life is in danger. I have little recourse but to remove the Borg technology.
JANEWAY: Which is the last thing Seven of Nine would want.
EMH: Hence the difficult decision. If a patient told me not to treat them, even if the situation were life-threatening, I would be ethically obligated to honour that request.
JANEWAY: This is no ordinary patient. She may have been raised by Borg, raised to think like a Borg, but she’s with us now. And underneath all that technology she is a human being, whether she’s ready to accept that or not. And until she is ready, someone has to make the decisions for her. Proceed with the surgery.

Here then is the central ethical dilemma. Seven of Nine is being held to ‘lack capacity’. Janeway is acting paternalistically, on behalf of the Federation, in what she feels is a construction of Seven of Nine’s best interests – even though the Voyager MDT is clear that Seven of Nine would not want this. Her junior doctor evokes the CRPD – ‘we must respect the wishes of the patient’ – but Janeway feels she has to ‘hold the hope’ of a full recovery for her captive/patient. Seven of Nine cannot be allowed to remain (cybernetically) disordered – she is at risk of organ failure – a radical intervention is mandated, whether or not in compliance with Intergalactic Law … [I hope by now it’s clearer why I pleaded with the reader to bear with me]

In post-operative recovery, Janeway does a bedside visit …

JANEWAY: I’ve met Borg who were freed from the Collective. It wasn’t easy for them to accept their individuality, but in time they did. You’re no different. Granted, you were assimilated at a very young age, and your transition may be more difficult, but it will happen.
SEVEN: If it does happen, we will become fully human?
JANEWAY: Yes, I hope so.
SEVEN: We will be autonomous. Independent.
JANEWAY: That’s what individuality is all about.
SEVEN: If at that time we choose to return to the Collective, will you permit it?
JANEWAY: I don’t think you’ll want to do that.
SEVEN: You would deny us the choice as you deny us now. You have imprisoned us in the name of humanity, yet you will not grant us your most cherished human right. To choose our own fate. You are hypocritical, manipulative. We do not want to be what you are. Return us to the Collective!
JANEWAY: You lost the capacity to make a rational choice the moment you were assimilated. They took that from you, and until I’m convinced you’ve gotten it back, I’m making the choice for you. You’re staying here.
SEVEN: Then you are no different than the Borg.

Janeway here is channeling Creon in Sophocles’ tragedy, seeking to persuade Antigone that she would be making the pro-social choice in choosing life and conformity over autonomy in death (I write about this a lot in other places). She tries to soothe Seven of Nine with the wisdom of her experience – she has seen others recover. Seven of Nine, from this particular perspective, is a serious case – the disorder took her over at a very young age – but in time she will learn that it’s worth coming in from the cold on Federation terms, even though she doesn’t see it that way right now.

But Seven of Nine, still using ‘we’ in her Borg identification with the Hive, has a perceptive question: if you get me better, so that I am then able to exercise my free will, will you allow me to return to the disordered out-group? Janeway is boxed in by the logic of her own position: she upholds the full recovery model and reasserts Seven of Nine’s lack of capacity. No change to the care plan, sorry, it’s all in your best interests, says Janeway … and Seven of Nine sees it clearly in the moment: I recognise you – you are my abuser.

A little later on, it’s time for Seven of Nine to start therapy – her body is restored somewhat towards a standard of normal functioning – her sense of panic has subsided – she is more compliant, although still held in seclusion – she has entered cautiously into a relationship with her treating team …

SEVEN: … I cannot function this way. Alone.
JANEWAY: You’re not alone. I’m willing to help you.
SEVEN: If that’s true, you won’t do this to me. Take me back to my own kind.
JANEWAY: You are with your own kind. Humans.
SEVEN: I don’t remember being human. I don’t know what it is to be human.
(Janeway picks up a [tablet] and lowers the forcefield.)
SEVEN: What are you doing?
JANEWAY: I’m coming in.
SEVEN: I’ll kill you.
JANEWAY: I don’t think you will.
(Janeway enters the cell, staying out of arm’s reach. She shows Seven the picture from the Personnel File [of Seven of Nine as a human girl] on the [tablet].)
JANEWAY:  Do you remember her? Her name was Annika Hansen … There’s still a lot we don’t know about her. Did she have any siblings? Who were her friends? Where did she go to school? What was her favourite colour?
(Seven looks at the picture for a while, then slaps it out of Janeway’s hand.)
SEVEN: Irrelevant! Take me back to the Borg.
JANEWAY: I can’t do that.
SEVEN: So quiet. One voice.
JANEWAY: One voice can be stronger than a thousand voices. Your mind is independent now, with its own unique identity.
SEVEN: You are forcing that identity upon me. It’s not mine.
JANEWAY: Oh yes, it is. I’m just giving you back what was stolen from you. The existence you were denied, the child who never had a chance. That life is yours to live now.

In a scene that seems to me to evoke forensic psychotherapy settings and seclusion facilities across many pathways, Janeway seeks, within a custodial frame, to engage Seven of Nine’s ambivalence and her repressed memories of her ‘pre-morbid’ condition before the trauma of assimilation by the Borg. Janeway is offering recovery but Seven of Nine not only can’t imagine what that might be like but is not at all sure there’s anything wrong with her that she needs to recover from. The emotional temperature goes up: Seven of Nine is aroused and agitated and distressed and confused but she can still clearly discern Janeway’s agenda, pressing upon her an identity that once was hers but with which she does not and cannot at present identify.

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There’s lots more where this comes from, as Seven of Nine’s ‘recovery journey’ continues and Janeway and her crew gradually increase her privileges and reward her progress with initially fearful and reluctant but gradually more trusting processes and mechanisms of social inclusion. As time goes on, Seven of Nine’s expertise by lived experience will come in handy, when Voyager comes across the Borg again …

But for now, it’s time to leave them to their travels and to come back to the Special Rapporteur and his recommendations. Where does this report leave the coercive framework for inpatient eating disorders treatment? The Rapporteur acknowledges the intense ‘stakeholder’ anxieties stirred by the prospect of radical change. Where would these units be, after all, without their medico-legal technologies?

I have seen people in Seven of Nine’s situation (by allegory and analogy) who, like her, came to feel grateful that their lives were saved by coercive interventions. I have seen others whose lives were saved in the strict (and short term) sense of the word but blighted at the emotional and existential level by the horror of the treatment they received ‘in their best interests’.

Obviously, I have no authority to make an ethical ruling here. The Rapporteur says that “instead of using legal or ethical arguments to justify the status quo, concerted efforts are needed to abandon it”. His position appeals to me and scares me in equal measure. But the point of this blog reduces to one question that inches its way into consciousness, in various different guises:

What if Janeway had wrestled a little deeper with the question of Seven of Nine’s fear of losing everything in treatment? Janeway makes a case for the ‘special patient’ – she pursues a justification for the excess of forced treatment by saying that Seven of Nine is ‘no ordinary patient’. But what if there are never ‘special’ reasons for using force? This is the axiom that we are being required here to accept.

The Rapporteur says we “lack the clinical tools to try non-coercive options”. What if the increasing power and potency and even sophistication of our medico-legal technologies (the Mental Health Act; the Mental Capacity Act; Community Treatment Orders; naso-gastric feeding; PEG feeding; pharmaceuticals and so forth) has deskilled us in some simpler forms of intervention? Suppose our coercive muscles are so well developed, that our engagement skills have become rather flaccid and feeble with disuse?

Suppose we invested in developing those skills in what Judith Herman called ‘existential engagement’, instead of falling back in relief, behind our coercive medico-legal redoubts, away from the stresses and strains of open debate? Suppose as many or even more lives might have been saved in creative ways, as have been lost to mishap or suicide under more coercive regimes?

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I don’t know; but I wonder …

 

References

Adlam, J. (2015) ‘Refusal and coercion in the treatment of severe Anorexia Nervosa: the Antigone paradigm’. Psychodynamic Practice, 21 (1), 19-35.                  https://www.researchgate.net/publication/265685587_Refusal_and_coercion_in_the_treatment_of_severe_Anorexia_Nervosa_The_Antigone_paradigm

Herman, J. (1997) Trauma and Recovery: The Aftermath of Violence – From Domestic Abuse to Political Terror. New York: Basic Books.

‘Star Trek: Voyager’ screenplays from http://www.chakoteya.net/Voyager/401.htm

 

 

“Nothing about us without us” – notes towards a draft manifesto for survivor-led emancipatory research

“The only true commonwealth is that which is as wide as the universe. I am a citizen of the world” – Diogenes of Sinope

“Education either functions as an instrument which is used to facilitate integration of the younger generation into the logic of the present system and bring about conformity or it becomes the practice of freedom, the means by which men and women deal critically and creatively with reality and discover how to participate in the transformation of their world.” – Paulo Freire, Pedagogy of the Oppressed

 

On a damp and foggy Paris day in December 2017, a small group of two survivor researchers, a philosopher, and a mental health practitioner (that last one was me) attended #ConfCap2017 to discuss and debate issues around the civic and legal and human rights of persons living with disability in the face of societal attempts, in certain circumstances, to restrict their liberty and to force treatment upon them.

We were invited to participate in a seminar/symposium in which we were asked to speak to this theme: ‘Exercice des droits et participation: entre contraintes et accompagnement: Recherche émancipatoire’. We began by considering the implications of Clause (o) from the Preamble to the UN Convention on the Rights of Persons with Disabilities:

“(o) Considering that persons with disabilities should have the opportunity to be actively involved in decision-making processes about policies and programmes, including those directly concerning them,” …

Some of the philosophical territory was set out and then we spoke about different ways in which our paths as users and/or as providers of mental health services and as activists, writers, researchers and consultants had intersected – how our ‘given’ roles had been creatively blurred in practices of equality in the field of mental health – how ’emancipatory research’ might be an organising idea for some of those practices and what the UNCRPD preamble’s ‘actively involved’ might mean in practice.

It’s these ideas of ’emancipatory research’, which I must confess I only first came across when I received this invitation, and the possible meanings of ‘active involvement’, that I wanted to write about here.

It’s in the very nature of the term ’emancipatory research’ that it would be a very bad idea to attempt to claim or define the term or to appropriate, colonise or enclose the open spaces the term evokes and signposts. Here I just want to see if there’s part of the map that’s not yet been fully charted…

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I didn’t know a lot about the terrain and so I poked around a little and had a couple of pointers from survivor researcher colleagues. I probably missed a whole chunk but here is some of what I found …

In a book published in 2000 called ‘Research and Inequality’, co-editors Humphries, Merten and Truman reviewed arguments for an emancipatory research paradigm and traced some of the theories and discourses interwoven under this heading. They began with the Enlightenment as a movement located in optimism about emancipation (from scholasticism and the tyranny of superstition and religious dogma). They noted the importance and influence of Marxism, feminism, post-structuralism and other similar discourses and they identified research models such as ‘participatory action research’ (whose lineage goes back to Paolo Freire), ’empowerment research’ and ‘collaborative enquiry’ as examples of emancipatory research practice.

For Humphries et al., following Freire, emancipatory research is ‘research which has an explicit concern with ending inequality and taking the side of oppressed and marginalised groups…Knowledge is not just about finding out about the world but about changing it’ (Humphries et al, 2000: p.4.) And Humphries asks an important follow-up question (p. 186): “What does emancipatory research mean if researchers are inevitably implicated in power, so that our efforts to liberate perpetuate the very relations of dominance?”

‘Co-production’ was not so much of a buzzword at the turn of the century but that ethos also carries ’emancipatory’ connotations, at least in theory (instead of ‘us’ the experts by training producing knowledge for ‘them’ the experts by lived experience, let’s ‘we’ join to produce the knowledge ‘together’). Some other time I’ll share our co-produced critique of ‘co-production’ but for now let’s peg it as ’emancipatory lite’.

Jerry Tew (2003) shows how the conventional established discourses around the gold standard (an interestingly outdated term, this) in scientific/medical research paradigms are located in an excluding and objectifying value base and suggests emancipatory research would have as its task:

“To produce evidence and theory (concepts and frameworks) that can enable users and carers to:

  • have a greater awareness of their situation so that they can make informed decisions and choices;
  • have more control over their lives in areas where this may have been taken from them;
  • participate in areas of social, economic, and political life from which they may have been excluded;

and can enable communities and practitioners to:

  • challenge stigma, injustice, social exclusion…” (p. 24)

Emancipation, in any domain, is not a process of continuous progressive trajectory or a question of the quickest route from A to B. There are an increasing number of survivor researchers and experts by both training and lived experience who are making significant contributions in the field. The concept of ‘survivor researcher’ was news to the audience at Paris ConfCap, however, and as Diana Rose, Sarah Carr and Peter Beresford (2018) note: “service users, survivors and their organisations are pre-defined as consultants in research and knowledge-making and not positioned as leaders, knowledge-makers or researchers themselves. We do not appear to be permitted to enter the same terrain or space as ‘real’ researchers.”

There is some ‘active involvement’, in other words, within the possible meaning of the UNCRPD, but it’s the kind of involvement that mostly comes from being ‘included’ in someone else’s project…

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Here is possibly where the United Nations again comes in handy. Bear with me while I reproduce what they say a bit.

The ‘Report of the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health’ (2017) proclaims (p. 6) that

“21. The promotion and protection of human rights in mental health is reliant upon a redistribution of power in the clinical, research and public policy settings.”

and goes on to recommend (p. 20):

“92. To address the imbalance of the biomedical approach in mental health services, the Special Rapporteur recommends that:

(a) States take immediate measures to establish inclusive and meaningful participatory frameworks in the design of and decision-making around public policy, to include, inter alia, psychologists, social workers, nurses, users of services, civil society and those living in poverty and in the most vulnerable situations;

(b) States and other relevant stakeholders, including academic institutions, recalibrate mental health research priorities to promote independent, qualitative and participatory social science research and research platforms, exploring alternative service models that are non-coercive;

(c) States partner with academic institutions to address the knowledge gap in rights-based and evidence-based mental health within medical education.”

So that’s a fairly clear rights-based mandate and indeed instruction to break up established monopolistic discourses determining research and knowledge production in the field of psychosocial disability (which term is broadly defined under the UNCRPD in a way that includes mental health issues and the contested domains of ‘personality disorder’, ‘eating disorder’, post-traumatic syndromes of various other kinds, etc).

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At ConfCap 2017 my colleagues and I looked back to the inspirational emancipatory pedagogy of Joseph Jacotot, concerning whom the contemporary French philosopher Jacques Rancière has written so eloquently. Jacotot, exiled to Flanders after the restoration of the French monarchy in 1815, discovered that he could teach French when speaking no Flemish even though his pupils spoke Flemish but knew no French.

Jacotot concluded from this experience that the role of the ‘master’ in relation to the ‘pupil’ needed to be entirely rethought and that “we are all equal in our intellect and common humanity”. Rancière critiques processes of social inclusion in which equality is constructed as a goal to be worked towards, arguing instead that we might simply assume equality from the outset and see how that changes our practice.

We also thought about the Democratic Therapeutic Community tradition in the UK since World War Two, beginning with a famous experiment in which Wilfred Bion, then an army psychiatrist in charge of the rehab wing of a military psychiatric hospital full of shell-shocked ‘soldiers who happen to be patients’, decided that his unit was in disarray and that the rehab task was hopeless unless the ailment could be displayed to the group as a group problem.

Bion formed an experimental therapeutic community centred around a daily parade ground meeting and invited the men to investigate their problems of discipline in wartime themselves, declining to exercise in any predictable way the medical or military authority vested in his role. The direct descendant of this approach was the Henderson Hospital Democratic Therapeutic Community, founded in 1947, which was the treatment centre in and around which, much later on, the paths of my colleagues and I converged.

At ConfCap 2017 we put the question whether this tradition of emancipatory practices of equality could be maintained and developed and we listed some of the ways in which we might be understood in different ways to have succeeded in producing knowledge together under this rubric and how this process has arguably become more emancipatory over time, at least in certain dimensions.

By this I particularly mean, that I was fairly clearly self-defining as project leader in my own early forays into research alongside survivors, whereas the roles have become gradually more ‘blurred’ (in therapeutic community terminology) to the point that recent and planned future ‘productions’ are either located in a practice of equality or may be understood as survivor-led.

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What then do I think I am doing, writing this blog and (for example) not even naming my colleagues? Well let me say first of all that I have not mentioned names because I am not assuming agreement with the train of thought I have set out here although I am very conscious of how strongly influenced it is by the collaborative work and I am not at all claiming thoughts as ‘mine’.

I also began by saying I was not going to make the mistake of staking out territory for myself or for my definitions of anything. Emancipatory research is a broad field and there might be something about this blog that justifies inclusion under that broad head, even if I am writing as expert by training.

What I want to do by way of conclusion is to jot down a few notes towards a manifesto or charter of some kind that might help to identify and mark ‘Survivor-led emancipatory research’ as an important and valued and differentiated subset of ’emancipatory research’ generally … and then see where it goes …

So – in that spirit – survivor-led emancipatory research is or might be understood:

(1) to be survivor led in design, implementation and publication
(2) to be embedded in flattened hierarchies and practices of equality that value expertise by lived experience
(3) to be concerned with, and to uphold a free and open and fearless culture of enquiry into, inequalities and dynamics of force within the system of care
(4) to renounce diagnostic models and categorisations that objectify the person in distress and not to objectify its own research subjects
(5) to place a value on deploying the self of the researcher
(6) to value communities of learning and to enlist experts by training in various fields as and when this may be helpful
(7) to value and privilege rainbow literature over grey literature

(8) to be understood as an anti-colonial practice and to resist and oppose discourses that would seek to ‘include’ it

(9) to be and to be recognised to be a form of knowledge production on equal terms with other such forms

(10)…..?

 

References

Paolo Freire ([1970] 1996) Pedagogy of the Oppressed. London: Penguin.

Jacques Rancière ([1987] 1991) The Ignorant Schoolmaster: Five Lessons in Intellectual Emancipation. Stanford, CA: Stanford University Press.

Diana Rose, Sarah Carr & Peter Beresford (2018): ‘Widening cross-disciplinary research for mental health’: what is missing from the Research Councils UK mental health agenda?, Disability & Society. DOI: 10.1080/09687599.2018.1423907

Jerry Tew (2003) Emancipatory research in mental health, in “Where you stand affects your point of view. Emancipatory approaches to mental health research. Notes from Social Perspectives Network Study Day 12 June 2003” pp. 24-28

Carole Truman, Donna Mertens, Beth Humphries (eds) (2000). Research and Inequality. London: UCL.

Report of the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health (2017) UN General Assembly – A/HRC/35/21 https://documents-dds-ny.un.org/doc/UNDOC/GEN/G17/076/04/PDF/G1707604.pdf?OpenElement

UN Convention on the Rights of Persons with Disabilities (2006) https://www.un.org/development/desa/disabilities/convention-on-the-rights-of-persons-with-disabilities.html