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IS THERE A LIMIT TO EMPOWERMENT?

Chris Barchard 2005

Empowerment sounds quite grand but it's worth looking at what it really means in the context of mental health. I first heard the word being bandied about in the mid-nineties by service commissioners when Community Care was coming in. I've spent quite a long time thinking about it and nobody has ever explained it for me. I don't know whether they really knew what they meant beyond perceiving a need to do something about the institutionalisation many people who were being moved into the community had suffered. For someone who truly recovers from their distress empowerment would seem obviously to be a natural part of that process - a return to being how you once were.

This is at one end of the spectrum but for most of us whether or not we believe it to be possible recovery can be incomplete. In any case even if recovery is complete access to opportunities we once had may not be. Stigma and discrimination are a reality and this problem is deep-seated.

I have some idea about my optimum potential if I was truly healed and it's hard to see myself being much better than that. Anything short of that could be said to be the result of some form of disempowerment. I have touched on institutionalisation, the state of one's mind and the attitudes of others. There are other basic things which disempower. I'm sure some of you have or are taking some kind of psychiatric drugs. Although these may have a net empowering effect on some they often have certain adverse effects which make it impossible to be at one's optimum while taking them. So taking these drugs may represent a trade-off for benefits in some areas at some expense in others.

I have always found the culture in psychiatry disempowering. From having few choices in a psychiatric ward beyond when to light up the next cigarette to being treated like a half-wit the system has not endeared itself to me. I have often been discharged feeling worse, on a regime of drugs that made me feel like I was trying to swim in glue and not having a clue what to do, with a near suicidally negative view of myself.

If you have experienced the kinds of things I have mentioned they may well have dented your view of yourself which may not have been that good when you entered the system. So a new and unwanted source of disempowerment can be the result of the others.

Empowerment is really more about re-empowerment in practice than adding something that was never there, trying to undo the effects of disempowerment. There are five main areas – material, medical, personal, social and work. Material empowerment is to do with having enough: having somewhere reasonable to live, owning things and generally having enough to live on. Medical empowerment includes getting the best out of the options for treatment, being put on an equal footing when talked to and not being subjected to social control. Personal empowerment involves the way you feel about yourself, how you are and your own interests and hobbies. Social empowerment is about feeling comfortable in the company of others or comfortable enough to get on with them and empowerment in work does not need a lot of explanation.

There can be no empowerment without the ability to make choices. Offering them is not enough. You can be so disempowered and ill-informed that you can lose the ability to make choices even if they are offered. A poor relationship with a psychiatrist relies on this. I have had to recreate a sense of self that makes me feel responsible for my life. I don't know whether anyone could create that sort of mindset for me but life without it was pretty unbearable. Along with this I have gradually lost a lot of my sensitivity to what others may think of me. Whatever they think I cannot do a lot to change. But how I react to it can do a lot to change how I get on with my life. I am able to make some choices now and have some energy. Perhaps the only thing others can do sometimes is not to stand in your way and allow you to grow. Then you will be able to make choices when the opportunities present themselves.

The idea of giving choices to patients is talked about quite a lot by doctors including psychiatrists. But as I suggested just now it may not always be very sincere. If you cannot cope without medication at least you need the best compromise on this: the drugs best suited to you in doses that are no more than you need before they start making you worse again, albeit in different ways. Having a psychiatrist who doesn't just leave things as they are because you're just getting by and who lets you in on the decision-making process is very useful. But to this day there is not a lot of information being given out by the system about the drugs so you'll probably have to do your own research if you are going to be able to make informed choices in this area. Getting the best deal with the drugs creates the optimum as opposed to the ideal climate for any other empowerment. I can remember a time not many years ago when the only available anti-psychotic drugs were so bad that the whole idea of empowerment seemed irrelevant. The only thing I wanted to do in those days was to get off the drugs. It was that unbearable.

Fortunately more people nowadays do not find themselves in that kind of situation and it opens the way to them thinking about things that are more the stuff of life.

Many people are on fixed incomes if they don't work but nowadays people are not living on grim wards nearly so often or in almost as grim bed and breakfasts. Something empowering has been done - a lot of people have been given reasonable accommodation. Some people are receiving enough benefits to live in some comfort, which is empowering. Materially some people have a reasonable base to expand from. The personal, social and work aspects of empowerment are more difficult to just lay on. However if you have a place with some privacy where you can bring friends it makes social life more possible. The personal and the social are intertwined because the way you are affects the way you get on with others. You also need neutral territory to meet people and the network of day centres has done a lot to create social networks in mental health. But the biggest questions now are about how far people can reach out beyond these networks and have social lives beyond them and what prospects there are for finding work and getting back to how they might have been had they not found themselves in the mental health system.

Clearly there is not a lack of raw talent amongst mental health system survivors, service users, clients, patients or whatever word you want to use. A lot of the problem is the shunning stigma of those who believe themselves to be all right. People may have problems of get up and go but these are not made any better if they think they will not get anywhere anyway. This is largely somebody else's problem and it needs to be sorted out. However I have reservations about the new government policy called “Social Inclusion”. I don't relish the prospect of being pushed into a social experiment where I go to a job that has been set up for me with a big push from the government who have no power to make me accepted by my workmates. Obviously some people will find this a lot easier than others and eventually it may start to make inroads into the problem of stigma and discrimination but as with all pushes for social change people are going to suffer. Unlike previous pushes for social change it's not those that need the change that are going to do the pushing but they will still be the ones to suffer.

It will take courage on behalf of us if empowerment is to extend beyond the confines of what is often called the “institution in the community”. The government is frankly ambivalent about its attitude towards us. On the one hand they say they want to tackle stigma and on the other they want to increase compulsion which is by implication stigmatising. Some of the measures they are trying out to tackle stigma, a case in point the programme called “Social Inclusion”, involve if not compulsion certainly pushing people. Whether this will in fact empower people by getting them to stand on their own feet or simply be a harmful exercise in social control has yet to be seen. For many of us the idea of seeking work unaided is unreasonable but it begs the question as to whether work in the open market is a good idea for us as individuals. The government should be careful about who it pushes or it will end up with hospital bills rather than saving on Incapacity Benefit. If it is really not a good idea to return to work then that sets a limit on that aspect of empowerment for some, for the moment at any rate.

Leaving this aside there are things that can help improve one's life whether or not one works. There are alternatives for some people to taking psychiatric drugs. The herbal remedy St John's Wort for one has been researched and can be more effective at relieving depression than anti-depressant drugs for some people. Some people manage to stop taking drugs and their lives are the better for it. But I would not advise anyone to do this without talking to their doctor because it can lead to disastrous results either because someone actually is benefiting from the drugs or because they were not withdrawn properly. Talking therapies can work and be better than drugs even and have long-lasting benefits after the course is finished. These talking therapies are not a joy ride though and their success is unpredictable. They can be soul-searching and hard work. Massage can do a lot to relieve tension if you are lucky enough to be able to afford it or have someone to do it for you. Listening to music can do a lot to ease the mind as can doing many other things that you enjoy. Having a good relationship can improve things and most people want one. There are many things you can devise for yourselves to empower yourselves which can be part of your lives as well as therapeutic. Art can be a release and a form of contemplation as well as having a creative end product for instance. Taking a long hot bath can be very calming as well as cleansing. It's important that you decide on these things for yourselves because otherwise they are not really so empowering. The whole empowerment game is about becoming more in control of your own lives with the sense of freedom that goes with this.

In all probability there are limits for all of us as to how close we can get to our optimum potential and do those things we feel we should be able to and have those things we feel to be our right. But to keep thinking about this can lead to a self-defeating attitude and it is true to say that we can surprise even ourselves. But if we are to ever find any contentment it is probably not a good idea to expect those surprises to happen. They still can. Since the closure of many of the big psychiatric hospitals there has been a huge amount of unrealised potential released. To date most of what has happened has been about providing alternatives to the asylums in the community. Nobody knew how things would work out but the programme has been vindicated. It will not end there. The biggest obstacle at the moment is not so much therapeutic as social and tackling this is indeed to break new ground. Never before in history have the asylums been emptied in the way they have over the last fifty years and particularly the last ten. We know we can survive outside asylums but we don't know whether we can make the undiagnosed majority include us in more of their activities. What is true today is not necessarily true tomorrow. With better treatment options and better understanding (better treatment probably makes us easier to understand) we become different people. And treatment needs to be seen pretty broadly here since it's not all about drugs but about housing, communication, social opportunities, self-help, talking treatments and alternative treatments. We don't need to continue to believe there is no future. I honestly believe that one is starting to emerge.

I believe there is a lot more scope for empowerment than is being tapped into at the present time. What I can do in National Voices Forum is to help people have a source of information and ideas because knowledge is power and can influence one's life in many ways and the more of us who are informed the better. Collectively we can influence the approach the system takes towards us. Empowerment is also by definition an individual thing. Some things that help can be provided. You have to take the power in the end and use it your way.

More about Chris Barchard at the Voices Forum

Also see the Discovering Autonomy Conference 2005