Twitter delivered an announcement this week from the Royal Australian and New Zealand College of Psychiatrists (RNZAP) proudly stating it had appointed a ‘consumer and carer representative’ to its governing body. The Australians have the irritating habit of tethering consumers and carers with each other in the same way that the song proclaims, ‘love and marriage go together like horse and carriage’.  We all know ‘consumers’ and ‘carers’ are two distinct stakeholder groups whose interests and perspectives do not always align.

I read further down the announcement, curious to know the identity of the ‘consumer and carer representative’.  As I expected, the new member is a well known ‘carer’ advocate, a good man, but less likely to ruffle the feathers of psychiatry’s leaders than many ‘consumer’ advocates.

I visited the RNZAP website to see who and how many sit on its governing body but found I had to be a member to find out. Not a good sign. I then looked at their constitution and discovered that the governing board has about as many members as a platoon or your average school class. I don’t envy anyone who has been selected to be a minority of one in such a crowded unwieldy arrangement.

If I wasn’t such a cynic I would probably congratulate the College on taking a very small step away from being a closed club to an open democracy. And I really should congratulate them, except I’ve seen modest incremental changes flicker and die too many times to believe they herald better things to come. I guess at heart I’m a revolutionary.

So, what would a revolution inside the world’s psychiatric colleges and associations look like?

I hadn’t really asked myself this question, but recently I read an interesting chapter on democracy in psychiatry, by US psychiatrist Bradley Lewis, in a book called ‘Liberatory Psychiatry’. Click here to find out more about the book.

Lewis starts off by writing there have been many liberatory efforts in psychiatry, starting with Pinel, and followed by the likes of Tuke, Freud, Liang and Szasz. He then makes the sobering observation that all these efforts at various kinds of liberation were crafted by psychiatrists, without the active involvement of people who use their services or of other stakeholders. He concludes that the systems these liberators devised ended up ‘skewed in rough proportion to the relative input and power of those involved’. 

New liberation efforts within psychiatry should not be expert driven, according to Lewis. Key stakeholders, especially service users need to be involved, not just at the point of service but all the way up the system, to our psychiatric colleges and associations. In short, psychiatry needs to become democratised.

The main barrier to democratisation is the privileged place science has within psychiatry over other forms of knowledge. But science, writes Lewis, is a human activity like any other – driven by biases, interests, power relations and blind spots. Psychiatrists often fail to see this but if they did, science would be demoted to the same status as other forms of knowledge. An inevitable consequence would be the democratisation of psychiatry, away from ‘internal elitism’ where only those who know the science make all the key decisions.

Lewis quotes the American Psychiatric Association (APA) motto: ‘Member driven. Science based. Patient focused’. How can an association with 36,000 members who are all psychiatrists be patient focused he asks. The APA can only achieve genuine ‘patient’ focus if it becomes democracy-based rather than science-based. Science is a tool; it should not be the foundation.

Lewis suggests we need to open the membership of psychiatric colleges and associations to other stakeholders, whose power through representation should be based on how much psychiatry affects them. Therefore, the membership structure would be weighted towards the people who use services, followed by their families. Citizens and other stakeholders should also be represented. This diverse membership would have the power to make decisions about psychiatric guidelines, training requirements, journals, research, infrastructure and finances. How would decisions ever be made with such as diverse membership? Lewis suggests that proposals not supported by the majority but with over 20% support could be considered legitimate knowledge, with the caveat that it is controversial and needs further investigation.

Thank you Bradley Lewis for giving us a glimpse of what a revolution in the powerhouses of psychiatry might look like. The RNZAP has taken the first step on what could be a long journey into unknown territory. My fear is that the College will stumble and lurch back to the safety of the home plate before they take another step forward. That step would be the inclusion of a ‘consumer’ advocate on its governing body.