An in-depth interview with Ron Coleman (with contributions form Karen Taylor) about recovery work conducted with members of the Democratic Psychiatry movement from Italy.
Q: Let’s start from the title of your book. You say that recovery is an “alien” concept, why have you chosen this metaphor?
Ron: In current mental health services, I think, within psychosis, recovery is not seen as a possibility; what is seen as the best argument has always been that what we do is that we ‘maintain’ people in a sick role. And so, calling recovery an ‘alien’ concept was really about challenging the establishments on recovery, because they would talk about recovery, but what they ‘mean’ is maintenance. I think recovery can be a reality, and not something that happens only to a few people.
Q: Thus the challenge, even at a conceptual level, is to oppose the very concept of recovery to the current habit of psychiatric services, in that they ‘maintain’ people – in a sort of static-passive-hopeless situation, even where they entertain people with their so-called, ‘”rehabilitative models”. This is a point you develop widely in your book. Can we say that your critique of the practice of maintenance does address also a “classical” psychiatric concept, the idea of “chronicity”?
Ron: I think the idea of chronicity is one that we have failed really to challenge, because in essence a “chronic patient”, is psychiatry’s failure, but we have never called it psychiatry’s failure – so we sanitise the failure by blaming the patient. In the same way, when someone is on medication and they don’t respond to medication, it’s never the drug that’s on fault, it’s the patient that’s on fault; the patient is “multi-drug resistant”, or “non-compliant”. So the focus of responsibility for failure is always with the client, or the patient. It’s never with the professionals. And in a sense chronicity is a way of saying that we have failed, but it’s not our fault, it’s the person’s fault.
If we allow psychiatry to do that, then what we are accepting is that “illness” is biological, and there’s no evidence really to come to that conclusion, or the evidence for that is very weak, it’s not as clear as they used to state.
Q: This reminds us a critical point, in fact a widespread misunderstanding, which is of special interest for us Italians. As you know the Italian critical movement in mental health in the 60’s and 70’s (lead by Franco Basaglia) has produced a deep criticism of institutionalisation as the main factor of “chronicity” in mental health. The disruption of the madhouse has been the main outcome of such a criticism, and this is a stepping stone of our history. However, after Basaglia’s death in 1980 – through complex and non homogeneous processes up to the present time – the fight against institutionalisation has lost its target, in a sense, by insisting on the ‘classical’ and macroscopic form of mental institution, the new and microscopic forms have been even more underestimated, if not neglected. For example, if we fight against the physical, visible strait jacket, but allow the widespread use of the ‘chemical strait jacket’, that is neuroleptisation of people (like Breggin and Bignami have widely shown1), there is a contradiction. Moreover, massneuroleptisation has been used as a presumed ‘tool’ to ‘facilitate deinstitutionalisation’, despite the fact that we should be well aware of the difference between de-institutionalising and de-hospitalising. What do you think of this problem, even considering the difference between the British and the Italian history?
Ron: I think that the idea that institutionalisation ended when we closed hospitals is a nonsense, because what it fails to recognise is that institution was not the ‘hospital; institution is institutional psychiatry, and more importantly it’s institutional biological psychiatry – where we create an individual who becomes addicted and dependent on a drug, that does more damage to him often than good (again I’d refer to Breggin and others for evidence of that).
We in this country still use ECT and we use ECT for some people as a preventative measure, so they get ECT even when they are not ill, it’s almost prescribed. And psychiatry claims for instance they don’t know how ECT works, but they do it. And when we do these things and pretend we don’t know how they work, again it’s about taking away knowledge from the clients, which would inform their choice.
So in Italian psychiatry, I think, Basaglia started a revolution in thinking, but what happened in time is what always happens with the establishment: in a sense the establishment knew they were losing, so they gave up then, they allowed it to become a ‘compatible’ reform, and then revolution ceased. But institutional psychiatry in Italy still remains and that is what institutionalises clients. If you don’t see a psychiatrist you can’t be institutionalised. It’s when you see the psychiatrist that you become part of the institution. And the way you will see that is that they never carried the thinking of people like Vygotskij, or Basaglia, or Foucoult, or Breggin: the thinking that the challenge to psychiatry is not simply the challenge to the hospital.
What is critical, within the asylum, is a practice that is based on coercion, or based at least on letting the client choose without giving him information. So, for example, they say to the client: “ECT is good for you; we don’t know how it works, but it’s good for you”. So we give him very little information, and he says, “OK, I will have ECT”. That is not people making a choice: that is people being coerced, and institutionalised into thinking, because institution isn’t the building; it’s creating people who think and agree with the power of the psychiatrists. So they think: “I am ill; this man or woman is a doctor; they know what’s best for me; therefore I must accept what is best for me; and if they say I must take this forever then I must take this for ever”.
That’s the institution. Emptying the hospitals can create the whole country as an institution, as a new hospital, because what we didn’t change is the practice. We changed where we practice, and we’ve done this in this country, in England, almost in part. We’ve changed where the practice happens, now it happens in your house, but if you are given neuroleptic medication in your house it’s almost the same as getting neuroleptic medication in the hospital; the only difference is the avenue, not the thinking. So the institution remains. But the institution was never a building, which is what people want us to believe. The institution is the power of psychiatry.
That’s the institution that has never been broken, and will never be broken while people believe that the psychiatrist is always right. And everyone tells us that the psychiatrist is always right. And psychiatry is different from other branches of medicine, because we are socialised into accepting the role of the doctor from a very small age. So we go to see a doctor, the doctor says, “you have something wrong with your kidneys”, and he treats it. So as you grow older, you respect the doctor because he always helps. So by the time you see a psychiatrist, you tend to be a teenager or older, and by then, already in your mind the doctor is always associated with something positive. So when you see a psychiatrist, who is a doctor and he says, “You need this”, you say, “thank you doctor!”, and like most doctors, they never explain what’s going on. But our experience of medicine in physical health tends to be good, so we accept initially that the doctor is only doing good. I think that doctors individually believe that they are doing good. But they have just never thought through themselves, and there is the institution, I think.
In a sense it’s part of socialisation, as a child being brought in a society where the doctor is respected, and parts of the establishment of psychiatry as a force of social control rather than a force of medicine. Because I think it’s when we come to elements of social control that psychiatry is more coercive.
Q: Now let’s address the constructive part of your book. You provide in fact a set of ‘guide-lines’ for an alternative to the practices of the current psychiatric system. You discuss in particular the ways of building and supporting the hearing-voices groups. In the light of your experience of conducting such groups and training people who will aid the establishing of new groups, what are the conditions or problems for accomplishing such tasks?
Ron: I think, establishing a hearing-voices group is, on one level, a simple process. It’s about bringing voice-hearers together; and sometimes they may not speak about voices initially, they will speak about other things, their identity has to be formed and people need to get to know each other, relax with each other, and it’s always useful to have someone who has been through the process.
The most important part of any experience of such groups is that everyone’s voices are accepted as real. So the reality of the experience is the cornerstone of the group. For example, when someone says they hear the voice of God we don’t say, “you don’t hear the voice of God”; we say perhaps, “what is God saying?” or “why are you hearing the voice of God?”
I think also one of the things that happen when voice-hearers get together is this tremendous sense of no longer being on your own, so there is a shared experience in terms of the effect of voices, although everyone’s voices are different; the response has been in some way similar, that people have been disabled in their life by the experience. And through sharing how people have leaned to cope with their voices, people do learn strategies that will enable them to increase the quality of their life.
I have seen that one of the strengths of the hearing-voices movement is that we don’t claim to be a cure. We actually claim that people who cannot get rid of their voices through traditional methods may learn to cope with them. And in a sense the only option left is to learn to cope; if nothing works, if drugs won’t take them away, if treatment won’t take them away, then perhaps the only thing left is to learn to live with them. I mean not to exist, but to live, and there is a difference: it’s not about people remaining disabled-by, but about people becoming enabled-to.
Q: How do hearing-voices groups usually start?
Ron: Groups start in different ways. Many groups in this country, in UK, have been started by professionals, some have been started by voices-hearers. It doesn’t matter, as long as the values of the group are: (1) You accept the reality of the experience, and (2) that no-one in the group is the therapist. If there is any therapy that happens at all, it happens as a by-product of the interaction between people. People don’t want the voices-group for ‘therapy’, and that probably is my greatest fear – about professionals trying to do hearing-voices groups now; they’re trying to turn them into a therapy, and be able to “measure” the outcomes, [Take boxes?] to do research and so on.
My problem is that now people are trying to create almost that group ‘CB-therapy’2, and that’s frightening: that’s all to cognitivise, behaviourise, therapeutise each other, that’s nonsense to me. The reality is that ‘therapy’ will always be a by-product of interaction. There may be therapeutic consequences, but people sit down to speak to each other, to explore and to try and understand their experience, they don’t sit down to say, “I am in therapy”. But that is what professionals want us to do: therapy. That’s the danger.
Q: Regarding the work of professionals, there is a part in your book where you suggest them in a different perspective, in order to cooperate with non-professionals for providing a truly recovery-oriented practice, within the services or the community. For example you write (p.71): “…the idea that the professional can remain fully an objective observer is a nonsensical notion, professionals are after all, humans. There is no doubt that professionals involved in hearing voices groups find themselves changing as the group develop. One of them told me that they felt as though the group had become part of their personal identity over their professional identity. He told me that for the first time in a long time he felt he was doing what he had trained to do”.
Ron: I think that when professional run the groups, the things that I always try to get across to them is that they are a part of the group, that if they are not a voice-hearer ( and I have no doubt that some are) then their role is to be an ally. They’re not there as a professional, they’re there as an ally. And as quickly as possible, they should allow people to do things.
I’ve had many professionals say that they try to do this and it doesn’t work. Then they must look at why the group is becoming dependent on them, rather than say that it’s the group fault, that they don’t want to take the lead and so on. So the question should be: why is the group dependent on me? And if the group is dependent on them, what do they have to change… that might mean they have to leave … and someone else has to step in and take up that role as an ally in the short term. Again it’s about this institutionalised process because the consumer (or the user) has been institutionalised into thinking that “therapy” exists: it’s something that’s done to you by the professional.
And so, even in England, where we seem to be very ‘sophisticated’ (in hearing-voices movement compared to rest of Europe) there still are professionals with a “high profile”: think this idea that professionals “know best” and so on the role of the voice hearer becomes subservient to that of the facilitator.
This is especially true where research has been carried out as a part of the process: that they want people to do certain things like check in and see what’s been happening in the last week, and ‘give structure’ to the group. That’s not so useful; it’s useful for research, but it’s not useful for people who might be sitting there hearing a voice say: “kill yourself!” What’s useful for them is to get to talk about that voice or talk about why they want to die; or more importantly, talk about why they want to live.
If professionals feel a need for a structure and force a structure on the group, then the group may achieve some things, but they will not achieve liberation, that is what the group should achieve. It becomes another form of maintenance. Why should people keep on going? … Once you choose freedom, or liberation, then you go on, on your own. And in time of crisis, that you need to go back and you say: I need to be here for an evening. And I think that’s the weakness [?...] And I think the other weakness is that you call it ‘self-help’. It’s not self-help, that’s the name they’ve given. It certainly is not self-help: there’s no such thing as ‘self-help’.
Q: That’s a good challenge or a wit! What do you mean by this?
Ron: If we say that a group is self-help. Then what we’re saying is that interaction between people is meaningless. Indeed, it’s rather ‘selves- help!’
What we do using the word ‘self-help’ is putting the focus of everything on the individual. What we are saying it’s individual’s problems; therefore individuals must find the solution. In the group what happens is rather a collective solution: the individual applies that solution for himself and is responsible in a sense for applying that for himself. But it’s the interaction between the group (as a society in a sense) that enables the person to become self-reliant. So the idea, “the self that does everything”, cannot be true, because self cannot exist in isolation; but it needs to relate to others in order to exit.
We were talking last night about the hermit, who lives in the cave by his own, must become insane to remain sane. So he must create voices or a fantasy around him in order to maintain his sanity. So in order to maintain sanity, somebody needs to be insane. (War could be an example, where men would have to go and kill: in order to remain sane they have to be insane, at the point of killing).
And in groups in self-help what we’re saying, what I think the right-wing would be saying, is that the individual is responsible for how they are now, or for becoming what they become. What I would say is that society has a responsibility for people’s madness, especially a society that makes us a unit of productivity, instead of a person. Therefore, the ‘society’ of people who are mad coming together is a way to create wellness, because when you have ten voice-hearers in a group and one non voice-hearer, then voice-hearing is normal. The person that is not normal is the non voice-hearer. Then, what happens is that the ten voice-hearers can relate to each other about their experience and understand that experience. You can know maybe their voices can be different in terms of ‘who’ they are, but the effect of voices in many people is the same.
Q: We’d like to ask you about an argument, that often we have had to confront, when trying to inform Italian professionals about the experience of recovery from severe mental distress. Especially psychiatrists are sceptical – you can imagine – and argue: “well, maybe it can happen but that’s an exception: maybe Coleman or Chamberlain are exceptional people, say in term of intelligence or education, but that can’t happen to the majority of psychotic people, especially people with a severely damaging condition as schizophrenia”.
Ron: I’ve had the argument around that I was not a … “normal schizophrenic” … I’ve had this argument so many times: but if I wasn’t a normal psychotic why did it take them 13 years to discover that? (This was my first response). And if these people, who don’t know me, had seen me 10 years ago they would have said, “he’s a schizophrenic”, because I fit into what they wanted me to be. The moment you step outside of what they want you to be, they have to find out an answer for that; and I’ve found out amazing answers about why am I now well. One was that I was never ill, at all, that somehow I just wanted to spend 6 years of my life as a hospital patient … as some sort of exercise, or research project perhaps. That because I have had an education, I was intelligent; I was able to achieve a better outcome than other people …
That is not true. It’s a non-sense. It’s a way for them to be able to look at their failure in the face and say: “because he’s exceptional and different, that’s why you are certainly not like him”; so it protects them, it does nothing for their clients.
I think it’s a very sad argument, an exhausted argument, that there is no relationship to the reality of my experience. Karen was speaking to my support-worker: why don’t you tell them?
Karen: Lindsey was his support-worker and we invited her to the wedding. She suddenly got in contact with us a couple of weeks ago. She tried to tell me on the phone about how he was like 10 years ago: “you know he was this typical “chronics”, or like typical “chronic schizophrenic” wandering in the streets, dependent on the drugs, not talking, not able to really go into it: typical sort of stuff. And she went to a training event that was run by our organisation, but Ron was at least 10 years ago, who totally could not believe what he is doing now. Because she had not heard of Ron Coleman in between, not heard about his writings or all he had done. Lindsey just told her she could not believe it was possible. Everybody I’ve spoken to said he was a normal chronic, chronically labelled schizophrenic. That is what he would look like to a professional: a chronic schizophrenic.
Q: Would you say, Ron, there was a point, or an event, where your recovery-journey started?
Ron: Lindsey, she took me to my very first hearing-voices group and I actually think that it was here that I started making the connection with my self. And this comes back to the importance of self, but self in context of society. Because it was there that I was able to start the journey that led to recovery. And the journey wasn’t a journey I made on my own. I think that if people have to make that journey on their own it will be very difficult to succeed. It would actually be much easier if professionals would join people on that journey, instead of trying to keep them where they are. Join them on the journey of discovery, because perhaps then professionals could recover themselves! That to me is part of the problem.
Karen: It’s all this professionalization of professionals: that in fact you must not build a friendly relationship with the person you are working with. You must not disclose yourself, you must not be yourself; you have to be the doctor, or the nurse! It’s crap, its rubbish. What Lindsey did, what other people have done: they have been themselves with Ron.
Q: You are insisting, Ron, on a topic which is central in your book: the close relationship between self and society. On the one hand, you underline the personal dimension of recovery, as opposed to the ‘clinical’ or ‘social’ reduction of the concept (see Carling or Warner’s ideas of recovery). But on the other hand, you seem to stress that the more we underline a genuine personal dimension the more we have to consider its social or ‘political’ value.
Ron: I think that we need to talk about the mind: the mind-body separation has to take off; in some way the mind and body are separate but together. And in a sense, it’s the same with self; self and society are separate but together and the understanding of self cannot be achieved without understanding society. And so to understand society, you have to understand society not only within a family context, or within relationship context, but also within a political context. Because there is no doubt that, within mental health context, psychiatry is a political issue. Do you want me to elaborate further on this?
Q: Yes, please. If you like.
Ron: I think you have to look at medicine as a discipline. If you are in an orthopaedic ward in a hospital, a ward for bones, you’re often referred to as the broken leg, in that sense. You’re not viewed as Ron Coleman, or Furio, or Karen, you’re just viewed as a broken leg. In psychiatry, the same thing has happened. You’re not viewed as Ron Coleman; you’re viewed as a schizophrenic, or a manic-depressive. You could become your label. So you’re not only Ron Coleman who maybe ‘has’ schizophrenia, which would be an adjective; you’re Ron Coleman a schizophrenic, which is a noun. And that is one of the problems.
Even the word patient or client is a noun: it labels … it’s not an adjective, it’s a noun. This person is a patient, they are not persons, they are patients. And the moment we do that, what we do is to take away their autonomy. We are saying you are no longer a person, you’re no longer Ron, you’re an object, rather than a subject. And the problem there is we cannot form a relationship with an object, that hasn’t any meaning; you form a relationship with the subject, so in order to break down for professionals they have to stop being a nurse, or a doctor, which is also a label, that of which makes them an object. So what you have in this ‘therapy’ is two objects; and if you have two objects instead of two subjects then there is no relationship. If there is no relationship there cannot be any therapy as a by-product; because it’s the interaction that makes us happy, or makes us sad, or makes us more in touch with our feelings.
Every time we need someone we get in touch with our feelings. So for instance when I meet Szasz, I’m angry because I’m in touch with my feelings, my disagreements about individualism against societism. That has an effect on me that makes me think and furthers me as a person, because I have to develop my arguments; when I see him I have to argue: “look- you’re wrong…” You can’t do that when you’ve got two objects; and moreover the assumption is that the professional is right and the client is wrong. Because one object is a carrier of power and the other object has had power removed.
The problem for the client, or the patient, is that we’re told that somehow professionals will ‘give us’ power, when the reality is that power is never given, it’s taken. As long as users do not take power for themselves then we’ll always have the institution.
Q: By the way, we wanted to ask you about a passage of your book where you say just this – “power is never given, it’s taken” – and suggest an analogy between the users/survivors movements and the women movements.
Ron: Historically, our power was something that was always taken, it’s never been given by the establishment. The women were never given the vote by men, they took the vote through action, civil disobedience and other conflicts; gay people took power over their own bodies in their lives; black people weren’t given power by white people, they took it. Gandhi is a classic example of someone who took power by … “doing nothing”, so to speak, by non-surrendering, but by becoming subject, rather than object. He was a classic example of real leadership … perhaps in a sense in psychiatry that is what’s missing, we have no leadership. Our leadership has not yet become subject, its still object; it’s still rooted in the institutional bases of power. People follow leadership, you know, in a way they don’t follow management. People will follow a leader because they are committed to that process, or purpose. People will follow a manager because they are paid.
We’ve been lacking for a number of years of real leadership. I think you felt the same when you lost Basaglia; the leadership went … the idea is still there but the leadership lacks, or the drive gets lost … In a sense in our country we have a similar problem (we have, I suppose, a lot of problems). The ideas are all there; there’s just no leadership. Even when we get to a stage where we gather people together … through time, perhaps, begin that leadership process, we spend so much time stabbing each other in the back, that we never actually do the job we were meant to do. Which is to lead, collectively, a movement against the institution?
I hope that will happen sometime: but I think we need to politicise our movement in a much clearer way than we are now. This is not about political parties, this is about real politics, the politics power; and it’s again about moving away from the diversions on single issues within mental health and see mental health as a whole, and see it as mental healthinstead of mental illness. And if you see that, perhaps we could develop a differently forward and our leadership will emerge.
Q: Thank you, Ron, for this conversation. Would you add just a word on your next projects or perspectives?
Ron: I think the future for us is to continue to build both our training and our conferences and publishing; probably the most exciting thing I see in the future is the development of a “psychosis unit” – a psychosis unit is a place for people in mental distress, which will be run differently from how the current psychiatric services are run. We will work with people in a very different way: through a process engaging with people in their belief system rather than in the institutions’ belief system; where we can train professionals to be people first and professionals second; where we can bring professionals and users together and in an alliance where everyone’s working for the same thing, rather than being in a continuous war against each other.
I think that if I had a wish for the future, I would like to see the end of the war between professionals and users, but not on a basis of surrender, on a basis of negotiated ceremony, where they acknowledge that both groups have a part to play in the whole.
.1 See Breggin, Toxic Psychiatry (1991) and Bignami (1992)
