Struggling for subversion: Service user movements and limits to the impact of client led accountability

Since the invention of the service user as a medico-political category, service user involvement has been advocated by policymakers and researchers as a way of empowering clients and ensuring service responsiveness and accountability in mental health care in the UK. However, our experience of involvement in this field over the past three decades suggests that these initiatives may have limited emancipatory impact. Service providers may be adept at ensuring that only certain kinds of service user voices are legitimated and heard, and more critical transgressive voices are sidelined. Moreover, service user involvement has implications which are seldom appreciated, such as the opportunities for patronage, co-optation of tame users and nepotism within the service user organisations themselves. The experiences we relate here suggest that as presently constituted, service user involvement and empowerment does not necessarily make users powerful. Indeed, without a careful reconsideration of the present arrangements for service user representation, it may well consolidate notions of passivity, medical models of human distress and deflect the liberatory potential of transgression. The implicit and sometimes explicit stipulations of what it means to be a ‘good patient’ attenuate the potential for meaningful change and obscure the exercise of power within the mental health system.