This year’s American Psychiatric Association (APA) convention was a charged affair owing to a number of factors, including the intense DSM V controversy, the recent high profile critiques of the profession (such as those by Robert Whitaker and Marcia Angell), the presence of documentary filmmakers shooting an expose on the APA’s role in an iatrogenic death from antipsychotics, and the new energy, participation, and strategies that Occupy Wall Street protesters brought to meetings. Out of all this, one of the most fascinating moments in the conference was when “APA Radical Caucus” invited psychiatric activists from Mindfreedom and the Icarus Project to their annual caucus meeting.

The invitation started with a protest meeting organized by Mindfreedom where Robert Whitaker, Jim Gottstein, and Keris Myrick spoke at the nearby Church of St Luke on “Imagining a Different Future in Mental Health.” This gathering attracted some members from the Radical Caucuswho then invited activists to come to the Caucus meeting later that evening.

The Radical Caucus meeting that followed turned out to be electric.

The Radical Caucus has existed for decades. Whatever radical or activist legacy it may have from the old days, for the last few years it has been more or less the same few psychiatrists meeting for presentations and discussions on political issues within and around psychiatry. A good conversation often occurs, then everyone goes out for dinner and drinks, and the conversation usually gets even better. But that is pretty much all that happens.

This year was already different because the protests and the controversies brought more psychiatrists, journalists, and filmmakers to the table than usual. Moreover, as already mentioned, this time there were representatives from the psychiatric activists groups at the table as well. The air was pregnant with energy and tension.

When the Radical Psychiatrists tried to conduct the meeting with a presentation and discussion followed by dinner and drinks the activists got angry. David Oaks, from Mindfreedom, led the way by refusing to sit quietly while the Radical Caucus proceeded with business as usual. He stood up, he got angry, he yelled, he sang a song, he put on his red nose, and he pounded on the table.

It was a dramatic and energizing performance.

Mr. Oaks was deeply concerned that the group lives up to its name, “Radical Caucus,” and that it take a serious stand on critical issues around psychiatric coercion and forced treatments. He was particularly concerned about forced electric shock treatments, which have been a longstanding Mindfreedom concern (for details see http://www.mindfreedom.org/campaign/electroshock-initiative ).

To my mind, what happened next was the most disappointing. The psychiatrists in the room attempted to normalize the conversation and they became defensive and self-justifying. They talked about how we should all get along and treat each other with respect and with proper decorum. They complained that they were being misunderstood because they are trying hard, they really care, they don’t want to hurt anybody, and they often feel they have no choice other than to use coercion and forced treatment, etc, etc. Some of the psychiatrists argued that there is scientific evidence to support forced treatment methods.

All of this made the activists even angrier and left the psychiatrists feeling more misunderstood and the meeting ended up in relative paralysis. That said, there was lots of back and forth, and everyone (psychiatrists, activists, journalists) did go out afterword for dinner and drinks. I had to catch a train, but I can only imagine that the conversation got even better!

What can be said constructive about such an event? First off, obviously it was a good try on everyone’s part. The key mantra of all medical activism—from Women’s Health, to ACT-UP, to Disability Rights, to Mad Pride—is NOTHING ABOUT US WITHOUT US!!! There’s a deep injustice built into the heart of healthcare where the primary stakeholders, the service users, are not included in creation of healthcare priorities, research, education, practice, and institutions. It’s so obvious a flaw that no one can seriously argue against it. Would women want men to decide “womens’ issues?” Of course not. It’s absurd. It wouldn’t help if the men said that they were trying their best and that they really cared. It also wouldn’t help if they said they were being “scientific” and therefore “objective, value free, and unbiased.” Trying hard and using science is not enough. The only solution to exclusion is inclusion.

So this meeting, for all its difficulty, was a move in the right direction. It brought key stakeholders to the table with at least marginal participants in psychiatric knowledge, practice, and institution building. Where it broke down, from my perspective, was that the marginal insiders, the Radical Caucus, did not think that the key stakeholders had the right agenda (I say key stakeholders because if any activists group has earned the right to speak it is Mindfreedom and the Icarus Project.)

The radical caucus psychiatrists did not know how to recognize that the last century of exclusion of key stakeholders from psychiatric knowledge-making means that the people who have been talking need to let the other side control the agenda. The 100 year psychiatric monologue of experts talking about “patients” needs to become a dialogue. That starts with talkers being quiet for a while and listening to the other side of the conversation.

To be fair, many of the participants in the Radical Psychiatry Caucus are also members of the American Association of Community Psychiatrists (AACP). The Radical Caucus may be mostly a conversation and dinner group, but the AACP has tried hard for a long time to redress the “nothing without us about us” problem. The AACP, more than any other group in psychiatry, has tried to take seriously the idea of “recovery” for mental health services.

This recovery approach, as many people know, starts from within the activist community and it calls for much more active consumer participation, peer support, and alternative choices. It also calls for a much more hopeful approach to psychic difference and struggles that emphasizes the goals of well-being, spirituality, community, and justice over simple symptom reduction.

Part of the reason that the AACP members of the Radical Caucus were defensive is that they think they have been trying to live up to recovery concerns. There are two main problems with being too self-congratulatory here. The first is the way that recovery has been taken up is largely controlled by psychiatrists rather than consumers themselves. It is the psychiatrists, powerful budget administrators, and increasingly big pharma marketers who are having disproportionate influence on how consumers can participate and picking which consumers are appropriate. That means many activists are increasingly wary about the way that “recovery” is being adopted. Second, and more to the point of this meeting, the psychiatric activists at this meeting were not talking about recovery. They were talking about coercion and forced treatment.

For whatever reason, and I’m not sure I completely understand it (although of course I can weave a story around it if I have to), psychiatrists, even radicals and AACP members, were unable to hear these concerns. It wasn’t like the activists were hard to understand. They were being very clear, even willing to go to dramatics, to help people know that to their minds the most important issue for the meeting was forced treatment. And, in view of the 100 year monologue of experts, why shouldn’t the activists get to decide what is most important?

The other constructive thing to say is that the meeting was also a move in the right direction in terms of building a coalition. One of the reasons that the radical psychiatry caucus has mostly turned into a dinner group is that they feel so disempowered relative to the larger APA. It is unlikely that the APA is going to convert to a radical agenda soon, so the next step is to build a coalition to unleash additional sources of power. Psychiatric activists are key place to build affinity.

Also, another important person at the meeting was psychiatrist Duncan Double from the UK “critical psychiatry network” (http://www.criticalpsychiatry.co.uk/). Dr. Double added important perspective because unlike in the US, in the UK, critical psychiatry really does function as a “radical caucus.” The critical psychiatry network actively challenges the NHS on number of issues, including coercion, confinement, and forced treatment. Since Western psychiatry is rapidly globalizing, resistance and radical caucus type activity are emerging around the world. These can be sources of coalition power. There is a recent international offshoot of the UK group, the international critical psychiatry network,”which would be a good place for the Radical Caucus to build affinity (http://www.criticalpsychiatry.net/).

There’s also increasing opportunities to build coalitions with humanities and social science scholars and students who are rapidly developing work in madness studies (seeLiterature and Medicine2009 28.1: 152-171.) Also, there are radical social workers, psychologists, physicians, etc.

For better or for worse, all of this affinity building will require new participation in the Radical Caucus from within psychiatry. The well-meaning psychiatrists who have kept it alive all these years cannot do it. It needs a new generation of energy. Maybe, just maybe, new revolutionary times will be the stimulus.

Bradley Lewis MD, PhD is an associate professor at New York University’s Gallatin School of Individualized Study and a practicing psychiatrist. He has interdisciplinary training is in humanities and psychiatry and his recent books are Narrative Psychiatry: How Stories Shape Clinical Practice and Depression: Integrating Science, Culture, and Humanities.