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Chris Barchard

There is no consensus as to what the term 'user empowerment' actually means. Its existence reflects a growing awareness that medical practice, especially in long-term cases, fosters helplessness. My own experience is as a recipient of psychiatry where these problems are particularly chronic.

Before I talk about empowerment, it would be worth looking at the way hospital treatment disempowers people in the first place. The admission process is the starting point. The patient is searched and sometimes has some or all of their immediate effects confiscated and is put in a pair of hospital pyjamas and dressing gown. They are given a medical examination, a psychiatric interrogation, bathed and told to go and sit down. At this point in time, they have no power at all. I can remember immediately reacting to this treatment by wanting to get up and do something, but this was taken as a symptom of agitation and pretty soon became real agitation. Although. admission is not as rigid as this always today, the general disempowering effect of it is much the same.

It does not end there. Initially, the nurses aim to monitor and control the patient's every move all be it nicely so long as they do not pose problems. "Would you like a game of table tennis? Would you like to eat now? Lets have a game of chess etc etc. I can't hack it myself. I always get the full treatment. Principal medication built up to as much as 600 to 800 mg of chlorpromazine a day and 80 mg of haloperidol and I am still fighting it. I have had a lot of delusions I admit, but this attempt to take me over always gets the same reaction. By the time I am discharged, I am but a shadow of my former self and I certainly don't think much of being told I am well at that stage. This may not be typical of all cases in psychiatric hospitals, but it is not unusual in psychosis. At worst, the enactment of 'user empowerment' amounts to saying "now we've got you doing what we want we'll ask you what you want to do."

Empowerment should be built into treatment from the earliest possible point. And at any stage attempts should be made to respond to any reasonable wishes expressed by the patient. Empowerment should be about giving information to the patient, to explain what is supposed to be wrong with them in an acceptable way and respect that they have a point of view too. After all, 'abnormal behaviour' is largely an artificial concept and still open to debate. Empowerment is about non-coercion, taking no for an answer and agreeing to differ. Empowerment is about respecting the patient as another human being. Empowerment is about letting the health and individuality of the person grow back more than trying to reprogram them. Empowerment has not so much to do with what is done to a patient as what they are allowed to do themselves and what is not done to them. Empowerment is meaningless if it is assumed that patients cannot teach professionals anything.

It is most difficult to empower people in the hospital setting. Never being out of the company of the rest of the ward is harmful. Having only the pokiest lockers is degrading. Being moved from one bed to another is disturbing. A room that is home to one for one's stay is not too much to ask. It provides a focus, enhances identity and enables one to 'get away'. Sitting rooms of varying sizes are desirable as well, making the ward more homely. The right to make drinks when they are wanted and sufficient places to smoke are also needed. Smoking still has a special place for most psychiatric patients as a help to getting through very hard days. So the setting can offer more choices and individuality.

The role of the staff is obviously of equal importance. The staff need to take more risks in communication. Positive fostering of insight is needed. At present if a patient guesses what is supposed to be wrong with them, they are said to have insight. Such insight is well regarded, but does it always have to be guessed? Are psychiatric patients always so fragile and impossible to reach that insight cannot be built on by nurses and doctors? Are the official theories of mental illness so frightening that they cannot be discussed with the people they refer to at any stage? How can any genuine therapeutic relationship exist when the therapists go out of their way not to level with their patients while apparently believing they have a monopoly on truth and reason?

The provision of decent environments, as well as listening to patients, informing them and thereby building proper therapeutic relationships with them are not desirable, they are of the utmost necessity if psychiatry is to succeed and gain the reputation it would like.