Social exclusion

‘You can’t argue with luxury flats’

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‘Up on Housing Project Hill, it’s either fortune or fame …’ [1]

Amidst the bustling if battle-scarred banlieux of South London, where generally I may be found, beating my barrel and pestering the passing populace, I observe that you can scarcely throw a brick across the grounds of a psychiatric hospital without it breaking the window of a luxury flat that’s popped up, seemingly out of nowhere, to grace what once were the rolling parklands of those asylums that of old delineated the darkness at the edge of town.

A périphérique, if you will, of places for the kettling and containment of worklessness and fecklessness and other invented psychosocial ailments – near enough to the capital’s centre, as Foucault taught us, to be projected into; far enough outwith the city walls to manage the fear of contamination.

Now that London has expanded its perimeter to the point that the M25 is the new South Circular, numerous White men in waistcoats have not been backward in coming forward to point out just how expensive land has become in what once was the outer rim and now is the ‘Zone Two/Three’ inner doughnut around the central hole of the capital.

What a lucrative and slam dunk, sure-fire winner of a business model Mental Health Trusts of various descriptions could be on to, these good people proposed, if they were to dismantle the old asylum buildings (think ‘spacious’, not to say ‘spreading’) and sell off the land to the pseudo-sanitised corporate fronts of offshore money-laundering syndicates, falling over themselves in their rapaciously desperate urgency to build de luxe apartment blocks where once walked wardens (think ‘atmospheric’, ‘historic’, ‘vibrant’, ‘cutting edge modern amenities – crèche, gymnasium, underground car parking, ECT suite, Clozapine Clinic[2] – all thrown in’).

Ever mindful – in their own particular and peculiar, one-eyed fashion – of what we have come to know as the ‘optics’ (and never ones to miss out on a good bit of spin if the price is right), I hear in my imagination those mocca-chino’d money-men also murmuring that there could even be new-build hospital units in the mix, if the Trust executives played their cards right. More compact, of course – smaller footprint and none of your old-school sprawl – but (you know the tune: you could hum it for me, I’m sure) perfectly formed, purpose built, fit for purpose, COVID-secure, environmentally-friendly, hybrid conferencing facilities: all the trimmings.

Look at it this way (quietly they insinuated, over their flat whites and macarons): who’s going to argue with luxury flats, if the pay-off is air-conditioned consulting rooms with anti-barricade locks, and flat-screen technology you could open a pub with?

Well, I mean to say, I ask you: what’s not to love?

***************

Now I don’t know if you the reader have ever previously come across the phrase “you can’t argue with luxury flats”, but I’ve heard it so often now that I have started to hear it as something a lot closer to an actual instruction to desist than an arch and knowing nod to the Zeitgeist, or a sort of pallid Stoicism about the common sensical and inexorable nature of it all. I rather fancy that before you can so much as mumble ‘antinomianism’ to yourself, La Cruella and her squalid band of cheerleaders will have made it illegal to ‘argue with luxury flats’ under some obscure but nakedly violent sub-clause of the Policing Act.

Cue a nation of nodding dogs, remarking sagely that ‘they must know what they’re doing’ or ‘someone must want to live there’ or ‘you can’t stop progress’ or ‘bringing service delivery into the twenty-first century’ – well, you know the sort of thing …

I do nonetheless feel moved to argue with luxury flats – and with hospital new-builds, their deniable and spurious offspring. I am positively hissing, in fact, and I would proclaim my pissedness from the rafters, if only the bulldozers had left any rafters (for afters). If indeed it is, any second now, about to become against the law to argue with luxury flats, then the Home Secretary may do her Braver worst.[3]  My barrel is easy enough to find and open to all elements, desirable or otherwise – no need for an anti-barricade lock here …

I will argue with luxury flats, and here’s how:

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To begin with, we must note that this land has been NHS land since the 1940s, and once it is gone, it is never going to be possible to get it back again. First, we pave the parklands, then we put up a parking lot and contract it out to make fortunes for cowboy enforcers while deterring visitors to the site; then we wash our hands of the well-being of future generations altogether. Instead of blocks of privately-owned flats encroaching inside the agora boundary-stones[4] of NHS hospital grounds, before we know it, there’ll be nothing but little outcrops of outpatient clinics engulfed by housing estates.

Examples abound (and I’m not going to name current names), but Exhibit One, m’lud, is the old Henderson Hospital site in Sutton – the building that housed the Democratic Therapeutic Community there for nearly half a century (after it eventually moved there from Belmont) was dismantled brick by brick and carted off, and now the only evidence of a system of health and social care is a shiny new GP practice, where, no doubt, post-austerity and COVID-19 and Brexit, you can’t get an appointment with a human being at any price.

Privatisation, to put it simply, means deprivation, whichever way you slice the cake. You could resource new hospitals without selling off land to developers: it’s called funding a national health service, and it only takes, say, sending a handful of Challenger tanks a year back to BAE Systems marked unused and surplus to requirements (at £5,400,000 a pop and change – or approximately the equivalent of the yearly saving that would come from the Government not spending any money on legal fees defending bullying or sexual or financial misconduct complaints against MPs and cabinet ministers).

Now I don’t wish it thought that I fume and fulminate out of some faux or toxic nostalgia for the ‘back wards’ and abuses of the old asylum system – nor indeed for the dilapidated nursing barracks that have accommodated outpatient and inpatient care in many of these places. But those open spaces mattered, were balm for the soul. There’s no therapy quite like sunlight through the trees, bird song and fox bark and the snail on the leaf.

You’d think that the architects (in both senses of the word) of the new-builds would have learned the value of this even as they drew up their plans to dig up the grasslands, but no! It can’t be monetised, so it doesn’t count. There’s nowhere now to walk except on pavements or parking lots, ‘outside’ spaces are now landscaped inside the new-builds – on artfully constructed roof gardens or enclosed courtyards – and of course you can’t actually open any of the windows in these buildings, for ‘health and safety’ reasons.

I also get it that there really is a housing crisis in the London area and that some of the new blocks that have arisen from the rubble of Victorian outpatient departments are designated ‘affordable’. Forgive me though while I quietly choke on that word ‘affordable’ in this context. They’re not affordable to the local communities most in need of them – although they are affordable to that well-known engine-room of the British middle classes, the ‘Bank of Mum and Dad’.

As for the ‘luxury flats’ – only money launderers can afford to renovate them and only money launderers can afford to buy them.[5] Only time will tell whether anyone at all actually wants to live in them. The housing crisis will escalate regardless, since the structural factors creating homelessness and displacement are intensifying rather than abating and ‘luxury flats’ and gentrification generally are precisely an example and epitome of this.

So, marvel not, my friends, at these shiny hospital new-builds, for they rise from the ruins of excluded communities and marginalised ‘patient’ populations – and the ghosts of generations of sufferers howl wordlessly as they claw impossibly at the reinforced glass walls of that ostensibly inviting new atrium.

And don’t forget that inpatient mental ill-health beds are down 25% since 2010 and falling, in the context of a rising and increasingly unsettled population. One thing these new-builds are not is larger – and of course the land on which that bed capacity could be restored…has been sold for luxury flats. Whatever the merits and demerits of medical model inpatient care for psychosocial distress and disability – both in principle and in practice – the reality in South London is that most of the time an NHS psychiatric bed is not to be had when it’s needed – but still those bulldozers and money-launderers rampage through the foundation and fabric of the post-1945 welfare settlement.

Spare a thought also for the invisible cost in terms of the wellbeing and viability of the various and numerous community teams who have been repeatedly and seemingly endlessly displaced and unsettled by the shuffles and decants they have been put through because the land their offices previously stood on has been sold for luxury flats. Outreaching mental health practitioners need a secure base from which to explore, but their needs and by extension their patients’ needs are never factored in to these increasingly complex ‘chains’ of moving house and not infrequently there is simply no room at the inn at the end of the chain.

Let’s not overlook, either, that in South London, that means there is a dimension of structural racism to the question of who gets valued and who gets dehumanised in this property gold rush. Plus ça change …

If I come last of all to the actual service users invited into those alluring new-build atriums to take a seat in those shiny new waiting areas, it is not to overlook that ultimately it needs to be all about these our fellow-citizens or nothing has been gained – it is just that I don’t wish to ventriloquise and it’s not for me to say what might be another’s experience of such a welcome.

I will say what my worry is, as a ‘mental health practitioner’ myself. I was kidding you not about those anti-barricade locks. They are on every consulting room door in one particular new-build I have in mind. They cost upwards of £5000 per door. The ‘forensic’ non-throwable chairs will also set you back something nearer four figures than two. Not that you’d want to buy one in the first place. Or try to sit in one. Let alone throw one at the designer.

Construct our fellow-citizens as ‘other’; attribute, across the divide we’ve just randomly established, diseases of the mind which we’ve often just invented in our lunch-break; corral and kettle ‘them’ like so many fish in a fish farm; get affronted when ‘they’ become vociferous in their objection to being so toxically othered; put up a Lord Kitchener-type poster proclaiming that abuse will not be tolerated – and see where it gets us. That seems to be the game plan.

And that’s why luxury flats can be argued with.

‘… if you’re lookin’ to get silly/you better go back to from where you came…’

[1] The lines that open and close this blog are both from verse four of ‘Just like Tom Thumb’s Blues’ by Bob Dylan, from his 1965 album Highway 61 Revisited.

[2] The footnote indicator here is to mark that, while I hope this little piece may support the theory that irony is not yet dead, the reader must know that there is absolutely nothing funny about the suffering of the people for whom these last two interventions are generally intended, or more broadly about the psy-industrial complex and its instruments of social control.

[3] I am conscious in making these references that the shelf-life of UK Home Secretaries has lately been shorter than that of the most transient and flash-in-the-pan of weblog posts, so: blink and you’ll miss her, but Suella Braverman is the one we have right now. Be afraid: be very afraid.

[4] This idea about holding open the ‘agora’ or public spaces against privatising encroachments, and the perspective of this blog generally, draws upon the argument in my book with Christopher Scanlon ‘Psycho-social explorations of trauma, exclusion and violence: un-housed minds and inhospitable environments’ and if some of this is of interest you can read Chapter Two open access via this link: https://www.routledge.com/Psycho-social-Explorations-of-Trauma-Exclusion-and-Violence-Un-housed/Scanlon-Adlam/p/book/9780367893316

[5] You’ll appreciate that I am using the term ‘money laundering’ in a broader than usual sense, to include asset-strippers and climate despoilers of every description.

The Diogenes Paradigm

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Announcing the impending publication of:

“Psycho-social explorations of trauma, exclusion and violence: Un-housed minds and inhospitable environments“

Christopher Scanlon and John Adlam – with a Foreword by Earl Hopper and Prologue by Anne Aiyegbusi

Routledge: New International Library of Group Analysis

https://www.routledge.com/Psycho-social-Explorations-of-Trauma-Exclusion-and-Violence-Un-housed/Scanlon-Adlam/p/book/9780367893316

No man is an island, entire of itself; every man is a piece of the continent, a part of the main … any man’s death diminishes me, because I am involved in mankind, and therefore never send to know for whom the bell tolls; it tolls for thee (John Donne)

…we are headed for a whole world of people searching for a home that no longer exists (Naomi Klein)

Our central theme and field of study is the operation of discourses of power, privilege and position, and of relations of domination, between privileged in-groups ‘in possession’ and oppressed and dispossessed out-groups. We explore how these discourses and power relations exclude individuals and sub-groups of people from experiences of belonging and potentiality in ways that are not only (re-)traumatising for those who are excluded but also deeply damaging and endangering for us all.

We locate ‘the problem of homelessness’ in the continuing inability, of this society in which we live and of those systems of care in which we have been working, to recognise and to integrate, into its responses and interventions to this problem, both the sociological fact of dispossession or not having a ‘fixed abode’ and the psychological experience of feeling disrespected or of not feeling welcomed or accommodated in increasingly inhospitable environments.

Our term ‘unhousedness’ denotes individual and group experiences of having been displaced, in ways that are fundamentally unsettling, from membership of communities, large or small, with which one either identifies or finds oneself problematically identified by others. Our concern is therefore with what it might be like to not have a place to belong – of what it might feel like to have nowhere to go and no-one to turn to in order to feel ordinarily safe (or safe enough) or to find refuge or asylum.

We offer a tool for the exploration of these psycho-social dynamics in the form of what we call the ‘Diogenes Paradigm’. This Paradigm is located in our own re-re-telling of the legend of the itinerant vagabond-philosopher, Diogenes of Sinope: of his encounters with his fellow citizens and his trenchant critical commentaries upon the State in which he lived. The Diogenes Paradigm is a lens through which to explore the politics of otherness and unhousedness, of provisional inclusion and structural exclusion; and a tool with which to analyse phenomena of reciprocal violence between in-groups and out-groups and the contested nature of the public/private spaces, within and outside the agora.

The fulcrum of our Paradigm is the legendary ‘out-reaching’ encounter in the ancient Corinthian agora between the irresistible force of the mighty empire-builder Alexander of Macedonia and the immovable object of the marginalised street philosopher Diogenes of Sinope.

We use the lens of the Paradigm to frame and potentially re-imagine the fraught encounters between in-group and out-group, between the inhospitable environment and the un-housed mind, both at the ‘micro’ level of the traumatised and traumatising system of health and social care and at the ‘macro’ level of climate disaster and human mobility and their intersections with carbon capitalism and empire.

At both levels we interrogate the claim that there is ‘no room at the Inn’: that Big Lie which is iterated by the welfare state in the grip of discourses of ‘austerity’, or by the ‘Metropolitan’ nation states of the Global North, as the unsettled peoples whom their projections of globalised power have displaced come knocking at the gate, in search of shelter from those storms that ‘we’ of the Global North unleashed upon ‘them’.

Central to the Diogenes Paradigm is our move to take the contested conceptualisation of ‘trauma’ firmly out of the Clinic and to understand instead psycho-social processes of (re-)traumatisation. The pejorative attribution of ‘disorderliness’ is only ever applied ‘downwards’ in the societal hierarchy, from privileged, mainly white, people in power, to less privileged others with less power. If we must retain the idea of ‘the disorderly’, then the Paradigm invites us to look ‘up’ the hierarchy to those Alexanderesque generators of disorder who govern us and who thrive upon the disorder that they generate.

We therefore propose that to be psycho-socially un-housed is most often a consequence of traumatic experience; and that to live un-housedness is also always re-traumatising: a violent and violating psycho-social double-whammy of what went before colliding with what is now, in ways that are deeply damaging to the possibility of re-imagining what might be yet to come.

Whether we are settlers or nomads, to be un-housed and dis-membered is something that haunts us now, as it did in the past and always will do – until the end of human-time. A properly psycho-social exploration of traumatic unhousedness does not locate the unhousedness in the un-housed mind of the individual but in the transgenerational, psycho-social dynamics played out between those un-housed minds and the current and historical inhospitable environments that un-housed them.

In our book we examine how the most vulnerable members of society – those whose psychosocial status is ‘unhoused’ and excluded – are victims of inequalities and structural violence, and how social policy aimed at promoting inclusion and integration often perpetuates and exacerbates these issues.

In Part One of the book, we redefine our thinking about the nature of unhousedness and unsettledness in inhospitable environments and our particular reconceptualization of psycho-social trauma and of (re-)traumatisation; and we set out our development of the ‘Diogenes Paradigm’ – a tool for the exploration of the phenomena of reciprocal violence between in-groups and out-groups.

In Part Two we use the lens of the Diogenes Paradigm to discuss these fraught encounters between unhoused out-groups and inhospitable in-groups at the ‘micro’ level of the traumatised and traumatising system of health and social care and at the ‘macro’ level of climate disaster and human mobility and their intersections with carbon capitalism and empire.

In Part Three we foreground issues of racial inequality, racialised trauma and the possibilities of anti-racist practice. We set out ways in which the ethics and the methodologies of activist research and anti-oppressive practice might enable us and others to push back into and against the wind of prevailing discourses. We ask what it would mean for white people (and white men in particular) to give up our power, position and privilege, or whether only violence can dislodge us. We pay particular attention to states and practices of equality and to states and practices of disappointment.

We conclude by discussing possibilities for the opening-up of community-based psycho-social conversations of different kinds; and we offer a roadmap for the creative re-imagining of the places and spaces in which necessary conversations about restructuring and reparation can become sustainable.

The book itself is but a start, and but one small part, of the conversations we hope to be a part of. We hope you will be drawn towards reading it, and we look forward to hearing what you make of it.

Of unhoused minds and the ‘personality disorder’ fallacy

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“So Koestler condemned himself to homelessness. All that remained were the ideas he dragged around with him like Job…Home finally was mind; home was homelessness; Koestler was the homeless mind.” David Cesarani, Arthur Koestler: The Homeless Mind (1998)

“The sufferer who frustrates a keen therapist by failing to improve is always in danger of meeting primitive human behaviour disguised as treatment” (Tom Main, 1957, ‘The Ailment’)

Recently, Barrelman gave a talk at the launch party of a book, in which he and a fellow Cynic have a chapter published. The book’s called Psychoanalytic Thinking on the Unhoused Mind. It’s put together by another comrade of ours – and a very fine volume it is too (this is the weblink if you’re interested).

Now, I get why the various chapters were collected under the rubric of ‘psychoanalytic’ and when I myself started off down this trail I admit that I hadn’t yet quite got over a lingering infection of Kleinitis that very briefly even threatened to develop into the rabid form of that ailment… However, as that other wandering Cynic once sang, ‘I’m younger than that now’ – and I find myself altogether more in the ‘psychosocial activism’ line these days.

Coming back to the main current of the whole ‘homelessness and ‘unhoused minds” project got me thinking about Cesarani’s famous rhetorical ending to his biography of Arthur Koestler – and also about another great twentieth century Central European Jewish author in the high literary tradition… Franz Kafka’s The Castle, as many of you may know, tells the story of K, whose profession ironically is that of land surveyor. K gets himself a gig in the eponymous castle – but no-one seems to know anything about it and he can never find the tradesmen’s entrance, nor can he find acceptance in the nearby village; and yet neither can he cannot go home.

As the following excerpt begins, K has been lying in wait, in the snow, in the yard outside the village Inn, to accost a fellow named Klamm: suspected to be a Castle official who could unravel K’s Gordian knot of longing, bewilderment and annihilation. K’s plan is derailed by a shaming encounter with a mysterious young gentleman (and accompanying flunkey) who orders him to move along and advises K that whether he waits or leaves, he will miss Klamm just the same…

“Then I’d rather miss him waiting’, K. said defiantly… K saw himself being left behind alone…both of them going very slowly, though, as if wishing to show K that it was still in his power to fetch them back.

Maybe he had that power, but it could have done him no good; fetching the sledge back meant banishing himself. So he stayed where he was, the only one standing his ground, but it was a victory that brought no joy…it seemed to K then as if all contact with him had been severed and he was now freer than ever before, no question about it, and might wait in this otherwise forbidden place for as long as he liked and had fought for and won this freedom as few others could have done and none might touch or banish him, barely even address him, but – this conviction was at least equally strong – as if at the same time there was nothing more futile, nothing more desperate than this freedom, this waiting, this invulnerability.”

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My ancient ancestor, that homeless, wandering, Cynical-with-a-capital-‘C’, manic street preacher of ancient times, Diogenes the Dog, was once found, (down on his dodgy knees) begging before a statue. The townspeople asked him what he was up to (for this is their more or less bemused role in all such stories: they are the Chorus). ‘Oi! Diogenes!’ they cried. ‘What on earth are you doing down there? You’re not going to get very far with that statue, now, are you?’ Diogenes replied: ‘Can’t you see? I’m practising disappointment’.

Now, for K, permanently displaced and snowbound, outwith the Castle walls, disappointment in the ordinary sense is a practice in which he will become very well versed. He can’t come in from the cold, in any direction. The more hopefully he travels, the more disappointedly he doesn’t arrive. But what I especially appreciate about the story is the hint of possession and constancy about K as he makes his stand and stakes out his resistance. It’s the only place he can stand – and in a moment of autonomy and self-possession, he comes to a realisation about this, however fleetingly. He could be understood as refusing the ride he is ambiguously and ambivalently offered by the mysterious stranger…the stranger certainly experiences him as having chosen not to take up the offer…but it now seems to me that, for K, it’s not a question of refusal. It’s more that the ride just does not compute. It’s a wagon he can’t imagine jumping onto.

When we started riffing off of the story of Diogenes and Alexander, we constructed Diogenes as refusing Alexander’s offer of accommodation, in an expression of what Zizek called Bartlebian politics – ‘I prefer not to’. According to this way of seeing things, K is saying: ‘I prefer not to catch a ride on any sledge commanded by you, Mister’. He ‘prefers not to’ cede any power or to banish himself – or to draw upon the example of Antigone, whose position in relation to Creon, the tyrant of Thebes, is very similar: ‘I decline to recognise your secular, public authority in any domain that pertains to my private and personal values and allegiances…’.

I celebrate anyone who can take and articulate such a stand but I now think that this reading is not quite right – that K’s resistance is more important than his refusal. I think where K takes his stand and stands his ground (K and Diogenes and Antigone and Bartleby and, say, Greta Thunberg) is in the only place he can stand. He resists the force that would drag him away from his moment of autonomy into what would in essence be someone else’s idea of how his narrative should read. The ‘Bartlebian’ moment is then the realisation of this – not the practice itself, but the reflexive consciousness of the power of the practice. Nobody can twist his arm into banishing himself.

The idea of ‘refusal’ remains significant – but its significance lies in the experience of the offerer, when he feels that the offer of accommodation is refused. It feels like refusal to the offerer, when his offer is not accepted. But the object of the offer may or may not have refused it. We know only this much: that the offer has not been taken up – at least, not on the terms in which it was made. The object of the offer isn’t ‘failing to improve’: it’s more like they’re resisting ‘improvement’.

One of the things that got me thinking about this was being part of a treatment team, being party to an offer that was constructed as having been refused. This was on an inpatient ward where the ‘objects’ of the offer were malnourished or starving people (mis?)constructed as or (mis?)understood to be suffering from ‘eating disorders’.

An entry would go on the progress notes: ‘food was refused’. Such was certainly the experience of the offerer – the nursing staff, for example, who have walked down the corridor with a tray in their hands and set it down beside the ‘patient’ – and then found themselves walking back down the corridor again, still carrying on their tray the untouched plates of food.

But I began to understand – and in fact, the ‘patients’ very patiently took my education in hand, in this regard – I began to understand that sometimes the sufferer, out of sheer terror, or bewildered and bewildering and circular rumination, hadn’t been able to come to a decision. The offer just did not compute. Like K in the snow, they had been able neither to move towards the offer or away from it. They had simply stood the only ground they knew how to stand upon in that moment. The offer – the offerer, even – had been resisted. It had not necessarily been refused.

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I think it does also behove us to resist. By ‘us’ I generally mean everyone, when it comes to pernicious discourses of any kind, but I particularly mean, for present purposes, those of ‘us’ who do the offering in such settings (or the writing about the offering). It may be, that as our practice develops, we may risk losing our compass – fluidity is our friend and rigidity our enemy, but fluidity is not the same as going with the flow.

For my part, as I get older (and older – or, remembering Bob Dylan again, do I mean younger?), I realise there’s stuff going round that I just can’t be doing with any longer. I don’t think that I mean this in self-deluded ‘heroic’ identification with some Wilsonian constructed outsider; but rather because it simply won’t wash and I decline to be aligned with it any longer. The lies and venality of our political classes, to give a pressing example: but the list is long, and I’m not here to have a rant. However, the one I particularly wanted to end by mentioning, by way of publicly correcting the record, is the deployment and weaponisation, within the system of care, of the contested diagnosis – the fallacious concept – of ‘personality disorder’.

Now the record needs correcting, because although those early papers were written in ‘critical’ mode, nonetheless, I’m sorry to say, the reader would possibly have come away imagining that there really was such a thing as ‘personality disorder’ and that all it needed was a spot of reframing. But it needs to be said very clearly that it just will no longer do to be telling people that the problem with ‘them’ is that ‘their’ personality is ‘disordered’, and that the remedy for this is a little more of that much-evoked and apocryphally ‘containing’ secular deity, Laura Norder. There is, in particular, and by logical extension, no such thing – no such illness entity – as ‘borderline personality disorder’. Note carefully that it therefore can’t be meaningfully researched, such as to test possible treatments for said non-existent ailment.

This is a blog and not a book (note to self: must write a book some time!) and so I can’t give you the whole lowdown as to why in the not so distant future the whole concept of personality disorder will only be found lurking in dusty box files in mildewed archives tagged ‘pseudo-scientific colonialist claptrap of the Industrial Age’. But a little history goes a very long way…

So next time someone uses the term ‘personality disorder’ about someone else, recall, if you will, Prichard’s 1835 definition of ‘moral insanity’, in which a diagnostic entity is inferred from a judgement on presenting behaviour and ‘the individual is found to be incapable…of conducting himself with decency and propriety in the business of life’ (this was before the present Conservative government was even a twinkle in the eye); and recollect that the formulation of ‘moral insanity’ was the medical ticket into expert witness status in the criminal justice system as psychiatry emerged as a distinct profession at the beginning of the nineteenth century (here I am greatly indebted to another fellow psychosocialist, David Jones, for illuminating some of this in his own comprehensive history of the development and deployment of the term…).. Remember the 1938 pronouncement of the psychoanalyst Adoph Stern that ‘it is well known that a large group of patients fit frankly neither into the psychotic nor into the psychoneurotic group, and that this border line group of patients is extremely difficult to handle effectively by any psychotherapeutic method’ – for this is the moment when the term ‘borderline’ came into the frame.

Fast forward then to 1980, amidst the tsunami surge of the neoliberal turn, when suddenly there was no such thing as society, the jobless we created were either ‘feckless’ or ‘on their bikes’ and only ‘hard-working families’ were beneficiaries of government policy: and the American Psychiatric Association published DSM-III with the caveat and proviso that its system was so imprecise that it should never be used for forensic or insurance purposes (and then fast forward to the sales figures for DSM-III, which very quickly persuaded those august gentleman of the APA that there might be mileage in more classifications and more disorders).

Pinch yourself on the cheek, therefore, next time you hear the term ‘borderline personality disorder’ and remember that it’s not yet forty years old and has been more or less discredited for at least half the duration of its (non-)existence. Remember Main’s warning about the risk of ‘primitive human behaviour’ being disguised as treatment. And ask yourself if this might not be a Bartlebian moment after all.

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I’ve stopped going along with the whole ‘there is such a thing’ discourse (as far as I can: I’m sure I can still be called out on this) and I’ve started actively resisting it. It’s kind of a liberating feeling (and I sincerely hope that it’s not only me that gets liberated, of course). You know how the way to negotiate the perilous web of a supermarket is consciously blinking, so that you don’t get stoned on the sounds, scents and settings spun by the marketing spiders as they pre-plot your purchases for you? It’s the same with all that stuff about borderline personality disorder. Once you start to resist, you’ll start to wonder how you ever got taken in. If there’s a single discursive practice we can pick out and say, well, no offence to Diogenes, but that old Dog has surely had its day, it’s what Edward Said in Orientalism called ‘othering’: by which he meant ‘disregarding, essentialising, denuding the humanity of another culture, people or geographical region’.

To which I would add the prefix: ‘toxic’.

Toxic othering: there’s much too much of it about. It’s like air pollution: you get so used to it, you don’t even know you’re dying. The only remedy is a zero emissions policy. When it comes to the homeless, the displaced, the dispossessed, let this new book, and maybe in some small way also this blog, be some part of the process, not so much of psychoanalytic reformulation, but of a psychosocietal process of resistance and realisation – I hope that a range of emergent practices may coalesce and cohere and crystallise (but not solidify) around it, as did K’s awareness in the snow – let’s all, indeed and after all, prefer not to go along with it a moment longer.

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

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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

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“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

 

The #PTMFramework debate – a Cynical view?

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It’s been a busy old time for Barrelman in the agora, these last couple of weeks, I can tell you.

There’s all my daily challenges to grapple with: practising disappointment by begging from statues; waving my stick at people who don’t agree with me; trying to track down, by hook or by crook, one honest man hereabouts. Exhausting, questioning everything, you know. Not a lifestyle choice either, mind you – what’s a barrelman to do? it’s not about ‘good or bad’: it’s just the only place I can stand and still be me.

And now there’s all this tweeting and blogging and altogether just so many more things to Question. Take this latest example. All Athens is buzzing with this new philosophical manifesto – calls itself the Power Threat Meaning Framework. Aims to overthrow the Metropolitan Powers That Be. Especially the Medical ones. Sort of offering a Framework for a Meaning-full Threat to Power, if you follow me…

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Now you know me, I reckon. If there’s one thing I can’t abide, it’s the Metropolitan (Metropolis – City State – what it says on the tin, really) system of care. Whole point of me and my dogs being holed up in my barrel, here outside the Temple and just along the way from the olive grove (where Socrates used to hang out and make a very creditable nuisance of himself, few years back) is precisely that I do not and never shall recognise the authority of the Powers That Be to tell me what’s wrong with me or how I should live my life.

They might offer to relocate me, like the Emperor Alexander (no less!) did when he popped by for a bit of outreach work the other day. Cool guy, as it goes. We had a good chat and discovered we even had the same teacher back in the day (of which, more later!) – but notwithstanding, I sent him away with a flea in his ear (‘get out of my light’, I told him – you should have seen his face!). I’m not taking anything from that lot on the terms they’re offering it – which is always and invariably, that they could take it away again if the fancy took them. I’m just temperamentally incapable of ceding them that kind of power, no matter how cosy and structured a retirement plan they might have in mind to buy me off and shut me up with.

Who do they think they are, might I enquire, these great city-States: with their bigwigs and their elite in-groups and their excluded out-groups and their categorisations and their unexamined lives? Not to mention their disregard for animal life and the ecosphere and their colonial wars of aggression and the undeniable fact that their economic prosperity is built upon slave labour and Knowing One’s Place (and Minding One’s Own Business). The ‘Philosopher King’ says ‘The cobbler should stick to his last’ – I mean, please? Plato? Don’t make me laugh!

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So, anyway, not only am I well known to be ‘anti’ Metropolitan systems, but I’m also imagined to be pretty much ‘pro’ more ‘Cosmopolitan’ systems (which is what the ‘Framework’ is – bear with me!). I reckon this is because of one of my recent choice put-downs, when some practitioner or other asked me where I was from. Trying to get some narrative coherence out of me, no doubt. I drew myself up and I looked my haughtiest and I told him ‘I am a citizen of the cosmos, thanks very much’ … and before you know it, everyone and his uncle are wearing ‘Cosmopolitans do it ecosystemically’ badges and doing mindfulness courses in converted barns out towards Delphi way …

Well, I’ll come back to this point a bit later, about what I’m supposed to be ‘pro’ or ‘anti’, if I may – there being a rather significant and in fact total misunderstanding of my position bundled up in there somewhere. But when this ‘Framework’ comes along and is proclaimed in the main square and it’s avowedly Cosmopolitan and pokes its stick right in the eye of the Metropolitan system, speaking up for social justice, even asking some excluded people what they think about it all – well, you can see how people would figure I’d be like ‘yay!’ and gung-ho and putting out the bunting along with the rest of them.

Sure as I’m sitting here in a pile of my own dirty linen and not giving a damn, they got very cross very quickly when I started shouting at them too! Conceive, if you will, of their disappointment. But what I am urgently keen to understand is this: what on earth did they think they were thinking, imagining me as their cheerleader?

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To explain what I’m getting at here, the first thing to question, just to spell it out, is what exactly might be the difference between the Metropolitan and the Cosmopolitan systems. Might be obvious, might not be …

Now the Metropolitan system likes to think it’s not a system, not really and truly. ‘There’s no ideology hereabouts’, you’ll hear the in-group protest – ‘this is just how it is’ and ‘you can’t argue with science’ and all of that.

Okay, so this in fact is nonsense of the first water, because there’s a very clear ideology to the Metropolitan system – and that is that power rests at the centre and it’s up to the in-group to decide who gets invited in or not. Nice work if you can get it, of course (trust me, I’ve been there – or in fact, maybe DON’T trust me, because I’m tainted by association – well, either way…).

The small print of the Metropolitan kind of invitation is pretty damn specific and its special trick is that it excludes even when it looks like it’s including (note those active verbs, peeps!). If you look carefully, it says ‘Dear Barrelman (or whatever your name is, we don’t much care, so long as we know where you live) – Dear Barrelman, you too can be a Citizen of Athens, do please feel very welcome to come in from the cold, but only on the following terms (cue 426 pages of conditions, exclusions and penalties)’.

And right at the bottom, in slightly bigger font, just so we’re all clear, it reads ‘IF YOU DON’T ACCEPT THESE TERMS, WELL, TOUGH. We’ll either force you to come in, by means of what we call ‘medicalisation’ or ‘welfare benefit control’ or some other form of slavery – or we’ll leave you out there in the cold, and good riddance’.

So that’s the Metropolitan system of care, you see, and it’s kind of democratic, so long as you are not a slave or a homeless person – or a woman. Every so often someone says, okay, sod it, it’s bloody cold out here, and they accept the offer and the small print, even if they don’t read it or agree with it, and they get themselves some accommodation. Totally good luck to them, say I: I’m not knocking anything about that at all.

But there is a ‘but’. And the ‘but’ is that the Metropolitan system excludes faster than it includes, so the societal problem, if you get me, the problem of inequality and borders and privilege and force and generally trashing the place in pursuit of economic growth so we can go off and mash (or get mashed by) the Spartans or the Persians or whoever – the societal problem stays the same.

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So the Cosmopolitan ‘Framework’ has a much-hated system to go head to head against. And all credit to them: they go at it and set about it with much vim and gusto. Our Cosmopolitan friends pull no punches regarding the violence of the Metropolitan approach to sending out invitations. And then they argue ‘let’s not include or exclude by force across a boundary like those Metropolitans do’; instead, let’s include gradually, across a porous boundary so to speak (like the boundary of the agora, in fact, which is just a bunch of standing stones arranged in decorative poses at fairly wide intervals along the edge of the marketplace – nothing like your Long Walls down to Piraeus or anything). ‘Let’s see what develops’ and ‘why not come along for the ride’ – that’s their much more friendly and congenial idea of an invite.

According to the Cosmopolitans, we’re all citizens and we’re all linked to each other and the thing to do is to bring people in from the outer rings (starting with foreign peoples in distant lands, when we’re not enslaving them of course, and working inwards from there) towards the inner rings (community, family, the self, you get the gist) – by keeping the focus on what connects us all and not on what divides us.

So they’re for frameworks rather than fences and for descriptions that connect, rather than labels that divide. They have got various progressive moves towards equality on the go and they worry about the effect of the post-Peloponnesian War recession on the morale of the citizenry and, generally speaking, I hear you cry, what’s not to love?

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Two things, actually (minor quibbles aside). Two things, and they’re quite closely connected.

The first is this: I hate systems. I just can’t be doing with them. People think I’m anti-Metropolitan because I’m ‘on the other side’. Me, I’m not interested in that kind of talk. I carry no torch for the Metropolitans; but I have a pretty strong hunch I’m none too keen on the Cosmopolitans, either – not if a system is what they are after.

I don’t think you can include by excluding. The Emperor Alexander can go boil his tail if he thinks I’m going to recognise his authority over me. But it’s no use the Cosmopolitans denying his authority. Question it – yes. Go for it. I’m all for that. But I’m pretty damn clear that most people figure he’s presently in charge. Ask the Corinthians, or the Persians, if you don’t believe me.

My saying Alexander should get out of my light is not the same as my saying he isn’t Emperor. He’s a bloodthirsty warmonger, make no mistake, but he’s the most powerful man on the planet and we may possibly never see his like again, IMHO. Him being Emperor doesn’t impress me in itself; but if I did want anything from anyone (which I don’t), I know it’s him (in effect) that I’d have to be asking. I’m not sure that the Cosmopolitans have quite worked out how to get round that one; but plenty of people around the marketplace seem to see this as a bit of a sticking point.

Be that as it may, I say again, it’s systems I don’t like. I’m a Cynic, you see? Now on account of me making myself a touch unpopular about the place (crapping myself in public, thwacking people who don’t agree with me, not bowing and scraping to the Macedonians, that sort of thing) people have taken to labelling me cynical with a small ‘c’, like I was being destructive or ‘doing it deliberately’ or something. “Get yourself a teaching job, Barrelman, instead of haranguing people all the time and being generally a menace to traffic – don’t you know there’s a war on?” – you know, the usual sort of thing. You’re either part of a hard-working family in this city, seems to me, or you’re out (or else you’re a Philosopher King, of course: in which case, you get other people to do the ‘hard-working’ bit and you live off of the proceeds) …

But there’s nothing ‘small-c’ cynical about me. I’m a Cynic – and Cynicism is not a System with a capital ‘S’ – it’s a practice (with a small ‘p’) and the practice is mainly around not being taken in by economic power, not identifying myself as a consumer and, above all, not taking anything as read EXCEPT that man and animal are all equal under the sun and let’s take it from there. I don’t concoct or proclaim ‘systems’. I don’t even usually write anything down at all. I made these notes for myself but I confidently expect none of my jottings will survive for Posterity and rightly so. You can’t enslave me with words: questioningly, that’s how I wander about the place.

This Cynical practice actually takes a lot of discipline, which is called askesis if you’re interested. Not bigging it up as a practice – just saying how it is. It involves another thing called parrhesis, which means speaking truth to power. Power comes along, like Alexander knocking on the hoops of my barrel in the agora – you speak Truth to it. Simple as. Fact that Power wouldn’t recognise Truth if you thwacked it amidships with it, needn’t deter us, right?

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The second thing ‘not to love’ is this: there’s a bit of an idea around that Cosmopolitanism is The Answer. You’re either Metro or Cosmo – no neutral ground allowed. But I’m here to say it’s not like that.

Once you have a system, on this scale, you’re including by excluding. It’s a binary. You’re ‘in’ or you are ‘not in’. Like I say, some systems have city walls with spikes attached; some systems just have waiting rooms with comfortable chairs and cute but informative signage in soothing colour schemes. But ultimately, the action of including leaves some people the other side of whatever line you draw, be it never so pleasing to the eye.

And once you have two rival systems, well, before you know it, they’re like an old married couple that have started to look like each other and the rest of the world just quietly drifts off, leaving them to bicker themselves away into oblivion.

And what’s more: these two systems already look a lot more like each other than at first meets the eye. Both the Metros and the Cosmos have a plan for including and both begin by including. They just have different ideas about who and how many to include.

The Metros don’t muck around much; abrupt is their middle name; they’ll bang you up or pewk you out, soon as look at you. The Cosmos, they’ve got gentle, ambient stuff going on so you don’t even notice you’ve crossed the line (or signed on the line, perhaps more to the point); gradualism is their game and someday all peoples of the earth will be connected to the centre. But the invitation to come along in is still being made. And by the way, I got to quibble this one quibble: the Cosmopolitans don’t actually seem to be very, well, you know, cosmopolitan, in the loose sense of diverse: not when it comes right down to it. Not so very different from the line-up of the ever-so-Metropolitan Academy across the way, unless you squint sideways…

Me, like I said, I don’t care for System but I set myself a practice and my practice is to be asking, right, well then, so wtf? Who gets to say where ‘in’ is – or where it ends and ‘out’ begins? If including is to be our business, then that’s no practice of equality. That’s some gradual working towards equality at some unspecified date – signalled to be sooner in the Cosmo camp, a whole lot later in the Metro camp, but not in anybody’s lifetime either way.

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I’m a Cynic and I may not have mentioned this before, but Cynic comes from kynikos, which means dog-like – or dogged, even, as in bloody persistent, not to say downright stubborn, in pursuit of a practice …

So now I got to run. Dogs to water, heads to bang. But here’s two last questions for you. You remember I mentioned that the Emperor and I turned out to have had the same teacher? Aristotle, was his name. Well, as you can imagine, I let him know in no uncertain terms, what I thought of his system. But some of his ideas did stick in my head. He says you need to have a clear shared idea of what the virtues are, if you want to have a clear shared sense of what a good, a good thing worth striving for, might look like.

Now I know this smacks a bit of Metropolitanism and telling other people how to be virtuous. Aristotle will come in for some stick on this point one of these fine days, and it will be well-deserved when it happens. But imagine it the other way – imagine a debate where each group in the debate has a different idea of what a virtue is and a different idea of what a good is. I hope it never comes to that, particularly if this city gets any bigger, but I tell you, it’d be chaos – and then we’d have to propose ourselves a new system – and then round and round and on and on it would go.

On the other hand, what would happen if we assumed equality was already the way of things, agreed our equality right from the outset, rather than shoring up the crumbling walls of our personal or collective discomfort about inequality by signing up to a direction of travel, feeling at best doubtful that we’d ever have to negotiate the tricky business of arriving? How would it be if we just decided there was no need for ‘in’ and ‘out’ anymore, so that there was nobody left to include?

Just asking …

Author’s note

Barrelman would like to be clear that he has written ‘Diogenesquely’ for literary effect and so as to inhabit and personify the points he would like to get across – but also so as not entirely to veil other parts of his (online and offline) identity (in anticipation of one set of objections, likely enough!).

If anyone identifies with any part of this analysis of the debate, or feels Barrelman’s lantern has chased away a shadow or two, that’d be fantastic. But this piece reflects Barrelman’s take on the #PTMFramework debate and is NOT intended as an attempt to ventriloquise anyone else’s voices. There are perhaps many contemporary Cynics and barrel-dwellers in our communities but they are fully able to speak for themselves and don’t need words put in their mouths by the likes of Barrelman.

A couple of historical notes to end with, if that’s okay, to anticipate one other set of objections. It must be conceded at once that the historical Diogenes, while doubtless a great questioner of societal morals and mores, was no respecter of women – in that, alas, he was a more ordinary man of his time – and so Barrelman’s critical observation about Athenian democracy represents an ahistorical hypocrisy, one from which this author would wish clearly to disassociate himself. Also, ‘Cosmopolitanism’ didn’t really exist as a philosophical system at the time Diogenes was creating havoc in the Athenian agora, so a certain liberty has also been taken on that score … a couple of other philosophical borrowings at the end, Barrelman likes to imagine, could have originated with Diogenes anyway, so there he craves your indulgence …

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

“I am Diogenes the Dog. I brown-nose those who give me alms, I yelp at those who refuse, and I set my teeth on those who are rascals”