Non-recognition and disrespect: being a ‘user’

An intriguing finding of the study was how the policy discourse of user involvement itself had disempowering and derogatory effects, and as such was itself very much contested by service users in the locality. This was partly due to the ‘involvement’ element of the discourse working to delimit the degree of participation and influence afforded service users. However, invisibility for ‘users’Footnote ⁴ was encouraged by the policy discourse of user involvement itself, and its associated practices, being centred around people being users of mental health services and categorising people according to their ‘type of mental health problem’ (see Lewis, Reference Lewis2005; cf. Hui and Stickley, Reference Hui and Stickley2007). In the face of this, the mutual support group strove to operate outside of both the ‘service user’ construct and the illness schema and conceptions of psychiatric discourse. And for the community group, such concerns eventually led to the ‘affiliation’ column being deleted from the signing in form for meetings. Yet the fact that group members struggled in vain to find a satisfactory alternative term to that of service user revealed the narrow discursive and semiotic parameters within which they were operating. As the following participant notes, this meant that the practices of ‘user involvement’ inevitably had reductionist, homogenising and pathologising effects through positioning people primarily in terms of their relationship to services (Beresford, Reference Beresford2000) and their concomitant ‘mental illness’:

So as this participant observes, in the context of user involvement people became occluded from view by their ‘mental illness’ ascription and status as a ‘welfare seeking being’ (Hoggett, Reference Hoggett2000). She notes how, in the field of mental health services, ‘service user’ as a discursive positioning constituted people in such a way as their ‘mental illness’ came to define them, along with the impossibility within the institutional confines of mental health services of eschewing culturally prescribed identities or of ideologically deinvesting these (Fairclough, Reference Fairclough1992). The discourse and practices of user involvement consequently had their own marginalising and dominating effects through social practices of objectification (Foucault, Reference Foucault1982) which differentially marked ‘users’ from others in a hierarchical relation (Williams, Reference Williams1999), and dividing practices (Foucault, Reference Foucault1982) in which some were deemed mentally ill and others were not – practices which support rather than help counter social exclusion whilst upholding the power and interests of psychiatry. These effects cannot help but be reconstituted in the course of user involvement, and, if internalised, can lead to self-alienation and oppression (Hoggett, Reference Hoggett2000) – effects against which the above participant is clearly struggling (cf. Hodge, Reference Hodge2005b). Furthermore, this identity construction resulted not only in status subordination as people became constituted as less than full members of society (Fraser, Reference Fraser, Fraser and Honneth2003), but also a kind of dehumanisation through an intersubjective process in which people became denied ‘wholeness’ (as Cresswell, puts in his contribution to this volume) and thus full humanity. As such, ‘service users’ were prevented from participating in the (semi-)public arenas of user involvement as full-fledged partners on the grounds of both inequality of social standing (Fraser, Reference Fraser, Fraser and Honneth2003) and unequal endowment with the moral rights of ‘the person’ (Honneth, Reference Honneth and Andersen1995).

These findings demonstrate how official movements towards valuing people and even attempts at universalist recognition can ‘set in motion a second – stigmatising – recognition dynamic’ (Fraser, Reference Fraser1997: 25).Footnote ⁶ The above participant's reflections reveal the way in which ‘user group’ politics in healthcare have often centred upon ‘claims for the realisation of personhood, for cultural respect, autonomy and dignity’ (Williams, Reference Williams1999: 673). Yet the very political alignments of user groups themselves work to simplify and reify group identities (Fraser, Reference Fraser2000), which ‘act back upon their incumbents’ (Taylor, Reference Taylor1998: 341) and to forestall mutual recognition (Crossley, Reference Crossley2004) and parity of participation (Fraser, Reference Fraser, Fraser and Honneth2003). In the context of mental health services, these effects are magnified by the stigmatising and all-defining nature of a ‘mental illness’ identity which it is impossible to positively assert (Hodge, Reference Hodge2005b; cf. Lister, Reference Lister, Andersen and Sim2004). Thus, through encouraging segregation and chauvinism, these dividing practices and resulting reification of ‘mental illness’ identities not only ‘risk sanctioning violations of human rights’ through constructing people as less than human, but also ‘freezing the very antagonisms . . . [they] purport to mediate’ (Fraser, Reference Fraser2000: 108).

The ‘stigma’ associated with having a ‘mental health problem’ and with being a user of mental health services was consequently a ubiquitous concern for many participants, often requiring forms of identity management since, as one interviewee pointed out, ‘nobody wants to be called a user’. Furthermore, many participants commented on the ideological and political effects of the ‘user’ construct itself. One female respondent commented, ‘most genuine people don't use, they contribute’, thereby indicating the ways in which the discourse constructed ‘users’ as deficient in certain respects (i.e. as failing to contribute) and therefore how it could work to undermine the value and efforts of individuals who became positioned as of unequal moral worth (cf. Fraser, Reference Fraser1997). Another male interviewee pointed out its implication in constituting relations of dependency as ‘a “service user”: it implies that you're addicted to them’.Footnote ⁷ Consequently, this participant refused the ‘user’ construction through adopting a purportedly more ‘respectable’ ‘patient’ one. Others resisted it through using variations such as ‘the user of the service’ or else moved away from user involvement circles in order to dissociate themselves from mental health services or to adopt a more politicised ‘survivor’ identity.

These findings illustrate again how welfare identity categories and official policies aimed at recognition can have unintended consequences through which they produce their own injustices of recognition. They also illustrate how these identity categories have become a focus for resistance within the organising of many disability, service user and survivor groups, underpinned by demands for respect, autonomy and dignity (Williams, Reference Williams1999). In the absence of a more fully developed and consensual social rights perspective in respect of welfare provision, the above participants were aware of how ‘users’ inevitably became ‘construed as inadequate, blameworthy or undeserving’ (Hoggett, Reference Hoggett2000: 193), and that the construction of dependence was a means through which power was exercised (ibid.) and which was corrosive of citizenship rights (Lister, Reference Lister and Lovell2007). Moreover, these injustices of recognition could be highly personally damaging and distorting, reflecting back to people a ‘confining . . . demeaning . . . and contemptible picture of themselves’ (Taylor, Reference Taylor, Taylor and Gutmann1992: 25), robbing people of ‘every opportunity to attribute social value to their own abilities’, and depriving them of self-esteem and self-realisation (Honneth, Reference Honneth and Andersen1995: 134). Again, it was an awareness of this and the indignation, hurt and anger this produced which informed participants struggles against such recognition denials and the importance they attached to such struggles (Honneth, Reference Honneth and Andersen1995).

The discourse and practices of user involvement thus had competing and contradictory effects, since they simultaneously worked to dominate, segregate and inferiorise ‘users’ and to open up spaces in which such hierarchical social relations could be contested and distinctions redrawn (Williams, Reference Williams1999). As the following participant points out, however, the powerful subjectifying effects of service users' social positionings meant the balance of power was very much against them as they attempted to engage in such action:

This participant clearly describes the reflexive constitution of personal and social identities (Fairclough, Reference Fairclough1992), or rather of ‘non-identities’ (being a ‘nobody’) for service users. The extract provides an example of the way in which social movements have challenged the denial of basic human rights on the grounds of how withheld recognition denies self-respect and self-esteem, which is dependent not only on being valued by one's social groups, but also on experiencing oneself as ‘valuable for society’ (Honneth, Reference Honneth and Andersen1995: 20). It illustrates well the injustice of misrecognition and internalised oppression (Bourdieu, Reference Bourdieu1992) for mental health service users who become constituted as dependent and helpless. It also illustrates how political action among mental health service users has, like that of feminism, been ‘a struggle for cultural agency’ (Lister, Reference Lister and Lovell2007: 160) and how forms of misrecognition can be both a social barrier and a motivating force for subordinated groups (Honneth, Reference Honneth and Andersen1995: 120). Importantly in this context, the participant points out as well how, in being constructed by social institutions, the dependency and helplessness of many mental health service users is at least in part ‘surplus’ and potentially remediable (Fraser and Gordon, Reference Fraser and Gordon1994; cf. Williams, Reference Williams1999). The quote thus also indicates the inter-dependency between social structural change and the realisation of citizenship rights, on the one hand, and the cultural realisation of the principle of equal moral worth and the achievement of symbolic justice on the other (Fraser, Reference Fraser2000, Reference Fraser and Lovell2007; Lister, Reference Lister, Andersen and Sim2004).

The ways in which these issues of status and self-esteem impacted on the achievement of participatory parity in user involvement fora (cf. Fraser, Reference Fraser2000, Reference Fraser, Fraser and Honneth2003; Lister, Reference Lister, Andersen and Sim2004) were evidenced by the research. At the first level, many participants, especially the women and a young male service user interviewed, described problems of ‘confidence’ about participating in group meetings, and especially in policy fora in which two women service users described feeling ‘like a fish out of water’. Inequalities of class also impacted here; there was an over-representation of those from higher social classes in the groups, and especially among those holding ‘user representative positions’, and whilst some group participants were of working-class locations, it was clear that this disadvantaged their participation in respects. For example, at one policy meeting at which I was present, a round of introductions reached a male service user of an apparently working-class social location at which point rather than in introducing himself, he remarked awkwardly, ‘I'm not really sure if I should be here’ and went on to remain silent for the course of the meeting.

At a second level, there was the ubiquitous issue of the status of user groups in the field of mental health services and in wider society (cf. Honneth, Reference Honneth and Andersen1995). On occasions when male psychiatrists addressed meetings of the groups, they tended to be allocated ‘prime time’ slots after which they departed, and there were times when user group members displayed deference towards service providers (who, for example, became thanked for their ten-minute attendance at a meeting). The following quotation demonstrates the pain and anger that injuries of status inequality, inferiorisation and misrecognition could invoke (cf. Honneth, Reference Honneth and Andersen1995, Reference Honneth, Fraser and Honneth2003; Wilkinson, Reference Wilkinson2005), as well as Fraser's (Reference Fraser and Lovell2007: 20) point, that ‘people can . . . be prevented from interacting on terms of parity by institutionalised hierarchies of cultural value that deny them the requisite standing’:

This quotation illustrates once more how user involvement, as a policy initiative, could have unintended consequences of reinforcing a low social status for participants, since although user groups can afford those previously unrecognised some value, and create social worth and meaning for members, the social and self-esteem to be derived from this is counterweighted by subordination for such groups in the wider social and cultural order (Honneth, Reference Honneth and Andersen1995). Through its participation in this order, and its being inescapably framed by dominant ‘systems of signification and representation’ (Lister, Reference Lister and Lovell2007: 161), which positioned participants as ‘comparatively unworthy of respect or esteem’ (Fraser, Reference Fraser2000: 114), user involvement thus simultaneously worked to reconstitute and reinforce an inferior, devalued and marginalised position for ‘mental health service users’ (ibid.; Lister, Reference Lister and Lovell2007; cf. Williams, Reference Williams1999). From this perspective, user involvement was reproducing – and also masking – the violation of justice it was officially aiming to redress: status inequality between service users and other social actors in the mental health system.

Moreover, this research evidenced how there could be practices of subjugation within the activities of user involvement themselves. According with other research (e.g. Rutter et al., Reference Rutter, Manley, Weaver, Crawford and Fulop2004), the accounts of statutory sector service providers tended to infantalise and patronise service users, constructing them in dialectical opposition to their own more ‘mature’ and ‘reasonable’ stance. For example, one made repeated reference to the need to involve ‘appropriate individuals’ who were ‘able to work collaboratively’, criticising both implicitly and explicitly the ‘behaviour’ of others who failed to take such an approach. Another referred to service users getting ‘too involved’ and finding it ‘difficult’ to adhere to the timeframe of meetings because ‘they can only speak for so long’. Unsurprisingly, such subordinating constructions were often experienced as disparagement by service users, especially the men and those with professional backgrounds, one of whom commented:

This extract highlights yet again the competing and contradictory effects of practices in the area of user involvement, which could be aimed at affording people value through inclusiveness, but result in being ‘insulting’ to some. It illustrates an ‘evaluative form of disrespect’ or degradation in the sense of diminished social esteem or status, and how such attributions can be injurious to self-esteem, how experiences of social denigration or humiliation endanger the identity of human beings (Honneth, Reference Honneth and Andersen1995: 134–5). It also demonstrates again how emotional responses from experiences of being disrespected and humiliated – indignation, anger, hurt – can provide the moral imperative and motivation for struggles for recognition (ibid; Honneth, Reference Honneth, Fraser and Honneth2003). Furthermore, whilst being particularly ironic and damaging in the context of mental health services, such necessary reactions to ‘psychological and emotional wounds’ themselves create their own wounds (Lister, Reference Lister and Lovell2007). Evidently, such situations left service professionals with a difficult balance to achieve, something also experienced by myself as I went about preparing and disseminating the research briefing paper for the study. This was particularly so as such discussions of ‘appropriate language’ and so forth for service users, referred to by the above participant, themselves work to constitute inequality due, as he notes, to the assumptions that underpin these.

The social–structural underpinnings of many of the claims of withheld recognition described above (Fraser, Reference Fraser2000) were thus omni-present and served to frame the interactions of the field. Participants' accounts were informed by an awareness of how they were socially positioned as mental health service users, and the intersections of this with their gender and class locations. Consequently, for those men ‘not used to being subservient’, as one put it, the recognition order and status hierarchy (Honneth, Reference Honneth, Fraser and Honneth2003) of mental health services in which psychiatrists were at the top and service users at the bottom was experienced as especially unjust and degrading. Many therefore engaged in forms of subversion and resistance to institutionalised relations and practices of social subordination (Fraser, Reference Fraser2000) whilst participating in user involvement activities. One participant, for instance, described how he ‘dressed up’ for meetings (‘a radical approach with a clean shirt on’), a kind of presentation of self (Goffman, Reference Goffman1959) viewed as a means of symbolically challenging the status service users were prescribed. Moreover, through their accounts in the research and other discursive arenas, in the recognition of the operation of power, and through seeking to expose and understand this, participants were engaged in symbolic struggle – both personal and social (Bourdieu, Reference Bourdieu1992). Theirs was a struggle for recognition of power operating within ostensibly benign, helping relations and institutions and of the effects of this for the service users involved, a form of political resistance dependent on moral insight into injustice (Honneth, Reference Honneth and Andersen1995) and of ‘imaginative agency’ (Hoggett, Reference Hoggett2000) which afforded self-respect and self-esteem (Honneth, Reference Honneth and Andersen1995). As I now discuss, these recognition struggles inevitably included battles against the constitutive work of the discourse of mental illness.

Misrecognition: the discourse of mental illness and issues of authority and credibility

Whilst user involvement has (ostensibly) been established as an attempt to value users' views and contributions, and there was limited expression and impression from participants in this research of deriving some personal value from taking part, their experiences were mainly described in terms of a sense of being devalued – or misrecognised – in the course of its activities. Indeed, in accordance with other research (e.g. Wallcraft, 2003; Connor and Wilson, Reference Connor and Wilson2006), there were complaints from service users about not feeling ‘listened to’ at all levels of interaction with services. At that of service planning and development, for example in the context of the treatment of a report of a local user consultation exercise, participants often referred to the difficulty of being ‘taken seriously’. Evidently being used to such inferiorisation, for the women service users there was often a taken-for-grantedness about this, whilst, following the discussion above, two of the men participants explained the phenomenon as being due to a lack of institutional status and associated ‘credibility’, one pointing out that unlike that of many service users, my work had the benefit of ‘academic respectability’. However, participants also implicated in this context matters of social identity in terms of [psychiatric] ‘labelling’, referring to the difficulty of asserting one's views, insofar as expressions of dissatisfaction, being upset, anger and so forth could become attributed to one's ‘mental illness’:

These extracts evidence the insidious workings of power within the field of user involvement in mental health services, which worked through psychiatric constructions not only undermining the authority and credibility of service users' views, but also individualising and pathologising these. Chiming with the discussions of Cresswell (Reference Cresswell2009) and Spandler and Calton (Reference Spandler and Calton2009) in this collection, they illustrate the centrality of an ‘illness’ concept in producing these effects. However, they also indicate the gendered nature of these as whilst both women's and men's criticisms could be put down to ‘depression’, the men's concerns risked simply being written off as ‘mad’. Such devaluing and discrediting, or ‘psychiatric disqualification’ (Lindow, Reference Lindow1991) can be understood as a form of symbolic violence towards service users (Crossley, Reference Crossley2004) who were battling for social recognition – of their views, their experiences, and indeed ultimately their humanity. The compelling injustice of this misrecognition as these struggles became turned back on the individual as a sign of their ‘mental illness’ or ‘madness’ was noted by the following participant in the context of discussing a long-standing dispute over the payment of his expenses for attending meetings:

This quotation illustrates well how distributive justice can be a form of recognition (Honneth, Reference Honneth and Andersen1995) and is often linked to social status (Fraser, Reference Fraser2000), along with the cultural valuation of one's efforts (Honneth, Reference Honneth, Fraser and Honneth2003). It demonstrates how the withholding of such recognition can be experienced as a social injury and the emotional as well as political and moral significance of struggles for recognition (ibid.) – for personal and social worth and esteem, and for human dignity – in such economic confrontations (Honneth, Reference Honneth and Andersen1995). From a human rights perspective, it also poignantly illustrates how the normative principle of being viewed as having ‘rational insight’ and a ‘reasonable moral agent’ (ibid.) which underpins our understandings of humanity, and therefore moral and legal legitimacy and the ascription of rights, is undermined when people are deemed ‘mad’ (Busfield, Reference Busfield and Morris2006; see also Spandler and Calton, Reference Spandler and Calton2009 this volume). Clearly, such undermining of one's personhood and humanity can work to have deleterious effects on interpersonal and therefore self-respect (Honneth, Reference Honneth and Andersen1995). The denial of social recognition for this participant implies his moral degeneracy (ibid.; Honneth, Reference Honneth, Fraser and Honneth2003) and, following Honneth, his struggle is not only for economic redistributive justice and cultural revaluation, along with associated social status, but also for universalist humanity and incumbent interpersonal respect and self-respect.

This issue of moral responsibility being undermined by psychiatric discourse also manifested in the research in the theme of ‘trust’ – both social and personal. The above participant insisted in the context of his interactions with services that little would be gained unless workers could ‘stop seeing people as sick people who can't be trusted’. Justice was for him, then, a matter not only of being afforded value, dignity and respect, but also of being recognised as a responsible moral agent of full integrity and common humanity (cf. Lister, Reference Lister and Lovell2007), of equal moral worth (Williams, Reference Williams1999). Coinciding with Cresswell's (Reference Cresswell2009) discussion in this collection of the ‘split experiential whole’, the particular importance of this was illustrated by another female participant's account of the de-authorising effects of mental illness constructions on subjectivity ‘to the point where you can no longer trust your own judgement’. Being denied universal recognition, then, being ‘misrecognised’, was to risk suffering not only ‘an injury to one's identity’ but also ‘a distortion of one's relation to one's self’ (Fraser, Reference Fraser2000: 109).

The subversive workings of psychiatric discourse, which could work to undermine service users' authority to speak and to act, were thus displayed here. Furthermore, the research illustrated the particular violence created when psychiatric discourse rubs up against an understanding of user involvement as conditional upon the advanced liberal ‘individualistic ethic of self-responsibility’ (Dean, Reference Dean2008: 6). At one meeting, service users became castigated by a senior male psychiatrist for failing to take ‘responsibility’ for their own problems, whilst their ‘dependency’ became construed as behavioural, thereby serving to obscure the actual social construction of this dependency and struggles against this (Williams, Reference Williams1999; cf. Connor and Wilson, Reference Connor and Wilson2006). In this manner, the discourse of psychiatry served to legitimate a denial of the right to participation. The extreme injustice of this in the face of the New Labour policy mantra of interdependent ‘rights and responsibilities’ of citizenship (Williams, Reference Williams1999; Dean, Reference Dean2008; Carpenter, Reference Carpenter2009 this volume) was particularly striking, since these areas of moral jurisdiction became mutually denied to users of mental health services.

The symbolic injustice of ‘psychiatrising’ as a form of misrecognition in all of these contexts was evident from, and indeed amplified by, its repressive effects. It worked to silence service users, especially the women, in the public and semi-public arenas of user involvement: one woman confided that it had led her to decide against raising an issue at a meeting, whilst a male participant described how awareness of the matter among service users meant he was one of the few prepared to speak out, even though the consequent ‘stress’ of this could have deleterious effects on his own mental health. It also tied to a great deal of suppression of criticism in user involvement fora and in the formal research interviews – something attributed by one woman participant to a ‘lack of self-esteem’. Furthermore, among the women, this suppression sometimes encompassed self-blame for problems experienced in interactions with services, and this seemed exacerbated by the effects of psychiatric discourse in personalising socially generated phenomena.

There were a variety of tactics through which people engaged in symbolic struggle in order to find an authoritative voice. These included discursive strategies such as the disciplining of language use so that qualifying or down-playing arguments were also at times a form of resistance and means of attempting to forge credibility, especially among the women, with the men tending to be more direct in their speech. There was also the male counter discourse of ‘madness’, used at times by the men to reclaim the de-authorising effects of a stigmatised identity and to pre-empt disqualification of their views. In addition, silence and refusal to participate in user involvement activities, and in the research, could have been understood in some cases as resistance, a refusal to subjectify oneself to dominant institutions, discourses and relations. Overall, however, the research evidenced how, rather than being challenged, the dominant cultural framework of psychiatry and its ideological and political effects became reproduced as well as reinforced in the context of user involvement, the discursive constraints of which left only limited space for subversion and resistance (cf. Hodge, Reference Hodge2005a; Stickley, Reference Stickley2006). Along with forms of non-recognition and disrespect, misrecognition as a result of the dominating effects of psychiatric discourse, and the discourse of mental illness in particular, thus also served to impede parity of participation in mental health service planning and policy-making fora for service users (cf. Hodge, Reference Hodge2005b) and thus to deny them full access in practice to their right to participation in this context (Honneth, Reference Honneth and Andersen1995; Fraser, Reference Fraser2000, Reference Fraser, Fraser and Honneth2003; Lister, Reference Lister, Andersen and Sim2004).