Keywords

These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

This chapter makes a case for workplace democracy grounded in trade union and service user movement alliances with a particular focus on the mental health context. We draw parallels between ideals for union and community organising, activist learning, the education of practitioners, and the practice of mental health care, including novel dialogic approaches. All of the protagonists on this territory, mental health practitioners, trade unions, universities, and mental health service user movement groups face specific legitimacy crises. A democratising turn holds open prospects for renewed legitimacy for all actors and organisations involved, though we should be alert to pitfalls as well as possibilities.

Everywhere, a Crisis of Legitimacy

UK unions have a significant image problem and are losing members, difficulties exacerbated by structural economic changes over time. Mental health services also suffer legitimacy issues, not least because of the dominance of a bio-medical model that serves to squeeze out more social understandings of mental distress. Practitioner groups such as nurses, comprising the majority of the workforce, are challenged by some quite particular and foundational critiques of their values and commitment, with common humanity and compassion called into question by high profile service failures (Francis 2013). Service user or survivor movements risk co-option and incorporation, and dilution of radical critique, by engaging in organised systems of user involvement and participation. Universities, which educate the mental health workforce in partnership with NHS organisations, have their own problems with legitimacy as they become increasingly commercialised, moving away from an ethos of knowledge production as a public good. All of this takes place in an increasingly neo-liberal age, where public services and the welfare state withstand the worst of economic austerity measures. As such, the NHS is prey to ideologically driven undermining of its value for modern times; a challenge rendered more potent as funding cuts cumulatively diminish quality of services.

At this juncture, it would be easy to become demoralised at the task in hand of defending our major public institutions or working for a society in which ideals of community solidarity, mutuality and reciprocity are ever more visible and valued. There is, however, cause for optimism. Progressive social change is always a possibility, and facing up to these legitimacy crises at the same time as fighting neo-liberal inspired austerity can afford opportunities to fashion new politics and ways of relating that embody greater democratic participation than most citizens have ever known. Immediately, these require mass acts of conscientization or its close relation, consciousness raising. Furthermore, such enlightened citizenship must be predicated upon stronger relational ties and a greater commitment to dialogue, respect for difference, and open-minded deliberation rather than dogma.

Focusing on mental health services in particular, and societal views of mental health, gives us the chance to create a new politics of mental health. Because mental health care can be compulsory and coercive, the social relations therein can alienate service users and staff alike. Peter Sedgwick in his classic text, Psycho Politics (1982: 256), foresaw the potential for democratic alliances to prefigure alternatives:

The achievement of this kindly and efficacious condition, for all patients and all societies, is the central problem of psychiatric care. It is also the central problem of social liberation.

It is this distinctly Freirian goal that this chapter is concerned with. In turn, we offer potential solutions to the various identified legitimacy crises and make an argument that some of these can be woven together in the mission to create more democratic workplaces for everyone’s ultimate benefit.

Reclaiming Legitimacy

Union renewal strategies aim to reverse decline in membership and promote participation of grass-roots members in internal democracy. These organising approaches are an antidote to an over-reliance on so-called servicing models, which render union members’ dependent on shop stewards and paid officials. On top of this, the members can appear to be in a private relationship to the union, recruited on the basis of non-workplace offers, with little attempt to induct them into ideals of trade unionism. As such, unions can seem hollowed out, lacking in effective social ties between members. The union response has been to initiate programmes of renewal built upon basic organising to re-establish internal social capital.

Large public sector unions such as Unison and Unite are also experimenting with renewal approaches involving alliances with communities: so called reciprocal community unionism. Taken together, these initiatives (re)create a sense of community within the union, alongside establishing more meaningful connections with the community beyond the workplace. For the mental health workforce, this means forging alliances with service user and survivor social movements.

Amanda Tattersall (2010) recognised three ways in which trade unions might establish relationships with communities and social movement groups. Only one of these represents a set of authentic, reciprocal relationships, where solidarity is built upon shared objectives that neither belong wholesale to either partner; not singularly workplace defined nor community defined, but mutually agreed. Imperfect solidarity models might include single issue, instrumental relationships that do not survive beyond a specific campaign or action, usually serving one partner more than the other. Better are coalitions grounded in some mutual interest, where joint involvement increases the power of a campaign and potential success, but, still, ongoing solidarity need not result. The ideal type seeks a longer term alliance, attempts to base this upon democratic lines, and lessens asymmetrical solidarity (Brown 2006). Effective solidarity between unions and communities needs to be built in advance of being drawn upon; that is, long before any protest action or campaigning (Wills and Simms 2004).

A relative failure of organising approaches to date suggests that unions also face crises of capacity and commitment amongst the membership and Gall and Fiorito (2012) cite Freire’s Pedagogy of the Oppressed in making the case for a synergistic interaction between mobilisation and union commitment. The challenge to build a more connected and capable membership crosses over with union learning objectives, with participatory learning opportunities seen as an integral part of the organising agenda (Findlay and Warhurst 2011; Forrester 2004).

Freire and Conscientization

It has long been recognised that mass education under capitalism is a tool for pacification and reproduction of a compliant workforce but, in the right hands and organised differently, learning can be emancipatory (Bernstein 1977; Freire 1971). Such liberatory education recognises the symbiosis of knowledge and power. Mutual learning is at the heart of social movement organising, challenging hegemonies and supporting cooperative linkages between movements (Horton et al. 1990). These approaches to learning embody an ‘ideal of educating for citizenship in a fully free democracy’ in contrast to ‘educating to serve a state’ (Adams 1975: 205).

Freire’s critical pedagogy is relational, dialogic, democratic and, at core, political. Whatever the context, learning pivots on conscientization, a process of political awakening realised in the interaction between participants, framed by mutual understanding, hope and love (Apple 2014; Gadotti 1994; Giroux 2007; Glass 2001; Roberts 2000). If emancipatory potential is to be fulfilled: ‘respect for the autonomy and dignity of every person is an ethical imperative and not a favour that we may or may not concede to each other’ (Freire 1998: 59). The enlightenment that occurs within a dialogic learning process potentiates the identification of and resistance to sources of oppression:

Learners together, in the act of analysing a dehumanising reality, denounce it while announcing its transformation in the name of … liberation (Freire 1971: 4)

Freire’s influence has been significantly felt in nurse education via theories of learning grounded in humanistic psychology if not fully-fledged critical pedagogy (McKeown et al. 2015; Mooney and Nolan 2006; Purdy 1997; Waterkemper et al. 2014) with explicit reference to new models of leadership and affinities for social justice (McKeown and Carey 2015, Waite and Brooks 2014). More extensively, Freirian practices have infused trade union, worker and community education initiatives across the globe or can be seen in movement activism or asset based community development initiatives (Alinsky 1971; Brown 2006; Horton et al. 1990). Thus, Freirian ideals of democracy and learning are prominent beyond traditional education settings, notably in the activism and organisation of new social movements that favour horizontal, participatory decision making and democracy. Many such movements subscribe to notions of prefiguration – attempting to exemplify a preferred form of society in the course of trying to achieve it. In the mental health context, Crossley (1999) has noted the possibilities for enacting small-scale experimental utopias, many of which are distinctive for the quality of their democracy.

Union renewal tactics have also been strongly linked to union learning strategies, often grounded in distinctly Freirian ideas of participatory education and, effectively, conscientization. Indeed, Brown (2006) goes further to argue that union organising and renewal efforts must connect with radical histories and pedagogies if they are not to lose all potential for achieving transformative change. Hence, TUC organising campaigns have been built upon a longstanding commitment to an Organising Academy and many union bureaucracies manage learning and organising together. Furthermore, the more effective union renewal approaches are essentially relational and well-suited to organising health care services (Saundry and McKeown 2013).

For Brown (2006: 42) unions must reinvent their attachment to popular education, revisiting and revitalising learning that:

[goes] beyond instrumental knowledge and skills … hold[s] things up to critique, to be named and renamed, … aims to uncover injustice and build solidarity in opposition to injustice. It is this practice that can contribute to a new education within unions and guide popular trade union educators.

For Jurgen Habermas (1986, 1987) deliberative democracy is a means for social change, and crises of legitimacy are almost always indicative of democratic deficits, which in turn precipitate movement formation. Bauman (2000) contends neo-liberalism has precipitated a state of liquid modernity, within which practitioner groups such as nursing struggle amidst organisational uncertainties and flux (Randall and McKeown 2013). Health care workers and service users have been particularly assailed by a welter of ideologically motivated, top-down reorganisations, without any meaningful chance to have a say in these changes. Furthermore, critical reviews of recent service failures have been wielded by politicians eager to undermine the legitimacy of a state funded health service. Paradoxically, the government has looked to increasingly centralised solutions whilst urging leadership at the local level.

Interestingly, some progressive thinking within the Department of Health has extolled models of so-called transformational leadership and a recent White Paper makes liberal use of Freirian ideas, linking democracy, social connectivity and community engagement (Bevan and Fairman 2014). Unfortunately, there is minimal evidence that democratic leadership ideas have gained any traction in practice. Conversely, typically inflexible hierarchies persist, and significant managerial and union time is devoted to discipline and grievance rather than participatory problem-solving or transformation. Moreover, the disempowerment of nurses and others is compounded by medical dominance.

As in any other work context, an increasing degradation of autonomy results in grass-roots nurses experiencing the alienation of diminished control over work pattern, intensity and content. A powerful source of alienation for nurses and other healthcare workers is the way in which their very caring identity can be undermined by fragmentation of tasks and lack of control over how the work is organised resulting in diminished amount of time to spend with service users, denuding the quality of relationships. In mental health services this is exacerbated by a concomitant increase in levels of compulsion and coercion. Ultimately, and closely bound up with understandings of what it means to be a compassionate, ‘good’ nurse, this results in alienation from ‘species being’ (Marx 1844: 1977); our innate desires to be of value to other people.

Workplace Democracy in Mental Health Services

Freirian influence in health care is also to be found in democratised approaches to research such as participatory action research, appreciative inquiry, and experience based co-design. These research practices conceive of the health care context, staff and service users, as a community with a potential to collaboratively imagine and implement new ways of relating to each other and organising work; akin to Freire’s notion of generativity. It is not without irony that more often than not any benefits of such participatory projects have to be orchestrated on a case by case basis, vulnerable to reverting back to type once single projects have been completed. For any transformational potential to be properly realised, the practices of participatory democracy would have to be implemented on a much larger scale into the management and organisation of health care services. Thus, a democratisation of the labour process is required (McKeown and White 2015). Ideally, such workplace democracy would have to be inclusive of all relevant actors, including the workforce and service users and their families and friends.

A crucial finding in the Francis Inquiry is that neither service user and carers voices nor some nurses and union representatives were able to successfully raise or escalate concerns over falling standards of care in the face of substantial management inspired, and Board approved, reorganisations. For these reasons, the Francis Report recommended improving systems for attending to employee voice and strengthening nursing union representation. Across the NHS there has been enormous growth in interest in service user or carer voice, leading to widespread investment in developing so-called service user involvement initiatives. These have been established at all levels from the idea of co-produced face to face care to strategic involvement in the planning and delivery of public services, with nurses in the vanguard of supporting these endeavours. Similarly, this ethos has also been reflected in the fields of education and research.

Despite some of the more progressive examples exemplifying dialogic, deliberative democratic principles, many service user involvement initiatives are effectively co-opted, much less explicitly democratic, and struggle to achieve substantial or lasting change in services. Indeed, it may be the case that service users and staff appreciate the process of involvement practices to the point where they are more likely to accept inertia to change; involvement and alliances as palliation rather than transformation (McKeown et al. 2014).

Arguably, the logical extension of trade unions’ renewal mission is the establishment of democratic worker control within workplaces (Simms et al. 2013). Various forms of workplace democracy have been attempted in a number of different industries and national contexts with beneficial impacts for organisations. Mostly, however, these examples of organised support for worker voice have favoured delegated representative forms, rather than participatory democracy. We have argued elsewhere that public services, with at least a rhetorical commitment to union-employer partnership working, could be opportune environments for enacting more prefigurative approaches to workplace democracy, and that, in the mental health context in particular this should combine support for both worker and service user participation (McKeown et al. 2014).

Initiatives for enabling democratic expression of worker and service user voice are essentially vehicles for cooperation and hence ought to be enjoyable in practice (Sennett 2012). Furthermore, we contend, they could be a significant tool to address the aforementioned endemic alienation for both service users and staff in mental health care. In the latter sense, democratised employment relations could also complement other democratising turns in care delivery, such as therapeutic communities (Winship 2013) or Open Dialogue (Seikkula and Arnkil 2013).

Conclusions

The self-same factors that threaten the legitimacy of our public services and educational institutions, trade unions and social movements can also be the spur for their renewal. Once suitably reorganised and reinvigorated, alliances forged between the latter can be the engine for radical transformation of the former. The tools for such a transformation are at hand, and a Freirian inspired adoption of democratic dialogic and relational practices for conscientization, grounded in a positive humanistic ethos, represent as good a starting point as any. The democratic transformation of mental health care, as Sedgwick foresaw, could very well prefigure social change on a much broader canvass. This appeal for democracy in mental health services must acknowledge its huge potential amidst routine denial; with service users and many practitioner staff lacking effective voice or influence, with progressive policy rhetoric somewhat blind to the realities of compulsion and coercion. Such contradictions would not be lost on Freire:

To glorify democracy and to silence the people is a farce; to discourse on humanism and to negate people is a lie (Freire 1971: 48)