Debate Over Inclusive Practices in Mental Health Policy Making

Nev Jones and Kendall Atterbury argue that appeals to rationality and evidence will marginalize service users in mental health policy.


In a counterpoint to a recent call for deliberative democracy in mental health policy making – as a proposed solution to “factionalism” in policy debates – Nev Jones and Kendall Atterbury explain how the core assumptions underlying deliberative democracy as a political theory are antithetical to an anti-hierarchical and inclusive approach to mental illness policy.

While rights-based approaches to psychosocial disability law and the UN’s Convention on the Rights for Persons with Disabilities require inclusion of affected populations in decision-making, the concept of deliberative democracy ties political legitimacy to rationality and evidence, concepts that are historically fraught with links to paternalism, white supremacy, and ableism.

Lonely man standing lost in the middle of a generic square with normal people arounWe have seen increasing calls to involve mental health service users in mental illness policy in recent years. Proponents of inclusion argue that engagement with diverse and critical perspectives is paramount to facilitating meaningful change in policymaking.

In the realm of research and knowledge production, increasing attention is also being paid to collaboration between service users, experts, and researchers. As Timo Beeker recently argued, the collaboration between researchers and service users may constitute a unique opportunity for observing the operation of social power.

Yet some have criticized the inclusion of affected persons in mental health policy-making as leading to factionalism and slowing progress. Specifically, William Smith and Dominic Sisti appeal to deliberative democracy and its component concepts of rationality and evidence as a “way out” of factionalism.

This appeal to rationality, Atterbury and Jones argue, “mask[s] the historical antecedents that have generated profound ethical, epistemic, and policy divides and are more likely to continue to perpetuate power hierarchies in the context of serious mental illness than they are to move us collaboratively through them.”

By appealing to rationality, Smith and Stisti’s approach “effectively avoids acknowledging fundamental intersections of mental health policy with structural and systemic racism, classism, heterosexism, and broader forms of ableism.”

“Coupling the ‘problem of factionalism’ with an appeal to deliberative democracy,” Atterbury and Jones write, “signals the political nature of psychiatric discourse and mental health policy while implicitly reinforcing the very politically charged conflicts they seek to resolve by appealing to a seemingly uncomplicated evidence base.”

In other words, appealing to rationality and evidence begs important questions regarding what counts as legitimate data and who has a legitimate perspective on mental illness policy – questions that are central to policy issues. This is especially the case in the arena of mental health policy, where patient and caregiver experiences have been “systematically marginalized in evidence-based medicine and subordinated within hierarchies of evidence.”

Including diverse perspectives and stakeholders in mental health policymaking may be slow-going and fraught with disagreement. Still, it cannot be side-stepped through an appeal to rationality and entrenched assumptions about what counts as evidence if we wish to see to overcome the persistent dogmatism in mental health advocacy and biomedical and clinical psychiatry and achieve the ends of equality and democratization.

When such dogmatism is an issue, the authors note, “deliberation easily defaults to power.”



Atterbury, K., and Jones, N. (2022). Overcoming Factionalism in Serious Mental Illness Policy Making: A Counter-Perspective. Psychiatric Services 00:1-3. 10.1176/ (Link)


  1. Not so sure about this–yes empiricism and rationality have limitations but the answer to bad science is not throw out science altogether, it’s to respond with better science.
    (Maybe in practice that’s what the author meant, challenging conventional epistemological narratives that privilege certain ways of defining truth).

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    • And to use science for what science is good for, but not forget that it has its limitations. Science can’t absolve us of the ethical/philosophical activities such as deciding what is good and bad in society, determining the scope of freedom when one’s activities impact another, deciding what purpose society has, whether and to what degree to enforce compliance vs. encourage creativity and free expression, and so on. Science (if used properly) is great at helping eliminate bias when determining truth. But it doesn’t help much with ethical issues where there is no absolute “True” or “False” involved. The entire area of “mental illness” is fraught with these ethical conflicts, such that no real “science” is currently possible in the field, since there isn’t even vague agreement on what a “mind” is, let alone whether a mind can have “health” and what a “healthy mind” would encompass. Not to mention the question of whether having an “unhealthy mind” would ever qualify one for involuntary imprisonment in the name of “health!”

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  2. Here we go again. More mental masturbation. Word salad. The arrogance of intellect. Academic bullshit. Piled higher and deeper. Get REAL, kids, if you can. To start, 1.: Psychiatry is a bogus pseudoscience & drug racket, which is NOT a legitimate branch of medicine, & must be seen and treated as the aberration which it truly is. Scrap the crap of psychiatry & 90% of all psych drugs. Or else nothing much changes much. Make the system SERVICE-CENTERED, and not a system-centered system as it is now. Make it a PERSON-CENTERTED process, and not a process-centered process as it is now. That in itself would solve the bulk of the problems. But over-educated idiots arguing bullshit will only keep us going round in circles. NO PROGRESS THERE!

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