In a recent post on this site, Bonnie Burstow explored the meaning of the term ‘antipsychiatry’ and coherently argued that the word should be reserved as a descriptor for those seeking the eradication of psychiatry. By contrast, in this article I use ‘antipsychiatry’ as a catch-all term to refer to the wide range of people who are, to various degrees, critical of Western psychiatry. Although accepting the importance of language, and recognizing that the word ‘antipsychiatry’ is open to more than one interpretation, semantics is not my focus here. My purpose in writing this piece is a pragmatic one: exploring how best we might harness this array of dissent so as to realize radical change.

If we are to achieve the much-needed paradigm shift in the way we respond to human suffering, it is imperative that the various strands of the antipsychiatry movement unite. Given the powerful vested interests sustaining the dominant bio-medical model, a fragmented opposition will possess insufficient power to transform the current mental health system. Indeed, the adage ‘united we stand, divided we fall’ has never been more apt.

As a vocal critic of Western psychiatry I actively engage in a variety of social media and, like many others on this side of the debate, often find myself embroiled in arguments regarding the most appropriate ways to help people who are experiencing emotional distress and overwhelm. Predictably, many of these spats are with biological psychiatrists and others wedded to ‘broken brain’ explanations. But — perhaps more surprisingly — I’ve witnessed a growing number of passionately expressed differences between people who each identify with the antipsychiatry movement.

What are the sources of these conflicting ideas?

I suspect that tensions within the diverse range of voices striving for radical change in our approach to emotional distress originate from three major sources:

1. Abolitionists versus reformers?

One important line of division seems to be around whether the ultimate goal of our efforts should be total eradication of psychiatry or its radical reform.

Many argue that the inherent inadequacies of Western psychiatry are so deeply ingrained as to render the current system beyond repair. It is reasoned that the ‘illness like any’ approach to human suffering, justifying the gross overuse of psychotropic drugs and a perverse approach to risk, is now so energetically defended by vested interests — the pharmaceutical industry and a psychiatry profession desperate to retain its status as a bona fide medical speciality — that the prospect of meaningful change in our mental health services is remote.

The abolitionists often highlight the human-rights violations, and the mental health legislation that legitimises them, as justification enough for calling for an end to psychiatry. They claim that the collusion between the state and medicine, enabling doctors to incarcerate law-abiding people and impose ‘treatments’ without their consent, propels a psychiatrist into the role of enforcer of the government’s desire to control those who they deem to be troublesome. These discriminatory practices, it is argued, can only be halted by the total dismantling of the institution of psychiatry.

In contrast, the reformers draw attention to pockets of good practice in the existing mental health service, where innovators are striving to change the system from within. Promising initiatives, such as Open Dialogue, are held up as evidence that radical change can be realised within the existing psychiatric service. They propose that critical voices need to focus on incremental, evolutionary improvements rather than demanding a revolution and the overthrow of psychiatry.

2. Service-user versus professional perspectives

The relative weights given to the views of service users and mental health professionals is another major source of tension within the antipsychiatry movement.

At one end of the continuum are those people who have, understandably, been alienated by their direct experience of receiving ‘treatments’ from psychiatry, and often feel traumatised by their time spent in the services — who assert that anyone who has worked as a mental health professional (medical or otherwise) is automatically rendered incapable of being an ally in the struggle for psychiatric reform. Making a living from collusion with psychiatry’s human rights abuses, the argument goes, is unforgivable and strips the person of any credibility as an opponent of the current system.

On the other side of the spectrum are those critics of psychiatry who assert that the vast majority of mental health professionals entered into these careers expecting to learn skills that would help reduce human suffering, rather than for the opportunity to control, dominate and abuse. Furthermore, from a pragmatic point of view they argue that if radical change is going to be realised, agents of change need to be operating within the psychiatric system as well as outside it. And given that psychiatric professionals typically possess much more power than the people they are paid to serve, it would be foolish and self-defeating to disqualify this potentially influential ally.

3. Societal influences versus individual responsibility

Critical voices pushing for alternatives to biological psychiatry all recognise that societal ills (such as homelessness, poverty, discrimination and inequality) contribute in a significant way to the level of mental health problems within our communities. Nonetheless, there seems to be diverse views about the magnitude of societal change that is necessary to achieve a radical shift in the way we approach human suffering.

Many people within the antipsychiatry movement argue that a marked improvement in the emotional wellbeing of our citizens cannot be achieved within the political systems that currently dominate the Western world. They claim that globalisation, and the capitalist philosophy that underpins it, are engine rooms for the divisions and inequalities that fuel mental distress and that the total rejection of these political systems is an essential prerequisite for radical change to the way we prevent, and respond to, human suffering.

Activists who support this revolutionary stance typically emanate from the left of the political spectrum and champion socialist ideologies. Within this frame, mental health problems are viewed as inevitable consequences of a sick society with the individual sufferers having little or no power to improve their plights.

In contrast, others arguing for alternatives to biological psychiatry put greater emphasis on personal responsibility as a vehicle for recovery. Espousing the virtues of choice and free will, those on this side of the debate typically seek to minimise state involvement, via policies or laws, preferring to allow individuals to navigate their own routes to wellbeing, unfettered by government interference. In a more extreme form of this philosophy, it is assumed that each of us, irrespective of the environmental context, possess the inherent capability to steer our escape from emotional pain via a sequence of rational decisions — in effect, to think our way out of our problems.

Unifying goals

If we are to realise the strived-for transformation in the way our communities respond to distress and overwhelm, a collective and coordinated effort will be required. It is therefore encouraging that, despite the above-stated differences, there may be discrete issues that can unite the assorted voices opposed to the current bio-medical dominance, thereby allowing us to collaborate on campaigns for change.

I will suggest that the achievement of three significant goals could bind the collective energies of those critical of traditional psychiatry. Predictably, the initial thrust of each will involve the rejection or dilution of an element of existing practice that is deemed to be unethical, ineffective or damaging to people suffering emotional distress and overwhelm. But it is insufficient for us solely to be ‘antipsychiatry,’ rejecting and dismantling the most unsavoury aspects of the mental health system; we need to chart a new course towards our desired paradigm by stating the alternatives that we would like to see replace them.

Taking into account the above, the following overview will be presented in two parts:

1. The unifying goal: The elimination of a specific part of Western psychiatric practice the achievement of which should find favour with all those critical of the current bio-medical approach.

2. The desired alternatives: The sort of structures and responses, dedicated to the reduction of human suffering, we would like to see instead of the traditional practice.

Unifying goal 1: More frugal use of psychotropic drugs

It is difficult to find anyone among those critical of traditional psychiatry who does not recognise the over-prescribing of psychiatric drugs. Since the late 1990s there has been an explosion in the consumption of so-called antipsychotics and antidepressants across the Western world.

Reckless marketing campaigns by the pharmaceutical industry, targeting all-too receptive doctors, led to these drugs being prescribed for problems outside of their original remit and over longer periods of time. Dementia sufferers and children displaying behavioural problems have been increasingly administered antipsychotics, while one type of antidepressant drug (the selective serotonin re-uptake inhibitors, or SSRIs) has been routinely prescribed for a wide range of anxiety difficulties.

This irresponsible expansion of psychiatric drug use occurred despite widespread recognition of the debilitating side-effects and discontinuation problems for both antipsychotics and antidepressants.

If this gross overuse was not bad enough, recent research seriously questions the efficacy of these drugs. A review of the studies regarding the efficacy of SSRIs concluded that the size of any therapeutic improvements were of no clinical significance and “the potential small beneficial effects seem to be outweighed by harmful effects.” As for antipsychotics, long-term use appears counterproductive and may be a key reason why ‘schizophrenia’ recovery rates in the under-developed world exceed those in drug-focused Western countries.

Desired alternatives:

– Small crisis houses in every town offering 24/7 respite care outside of a medical setting, and staffed by people displaying the core human qualities of genuineness, empathy, respect and compassion.

– Peer-support networks that offer routine access to one or more people whose previous experiences have included similar emotional crises.

– Information about psychotropic drugs that is freely available and that provides a balanced overview of their pros and cons. Such a resource would include reference to the mode of action (creating abnormal — albeit potentially preferable — brain states rather than restoring balance), the likely side-effects and the discontinuation difficulties following long-term use.

– Soteria houses routinely accessible, offering non-drug alternatives for people suffering with overwhelming psychotic experiences.

– Open Dialogue approach freely available to support both an individual struggling with psychotic experiences as well as the person’s immediate social network.

– Societal changes to counter adverse life experiences (such as intra-family abuse, discrimination, poverty and homelessness).

– Counselling and talking therapies routinely available, together with concise, non-partisan information about their rationale, content and limitations.

Unifying goal 2: The reform of mental health legislation

Mental health law across the Western world represents a form of legalised discrimination against people deemed to be suffering with a ‘mental disorder.’ Existing legislation allows innocent law-abiding citizens to be forcibly confined within a psychiatric hospital and compelled to ingest psychotropic drugs, routine practices that grossly infringe basic human rights.

In England and Wales, the government’s irrational preoccupation with the threat to public safety posed by those identified with psychiatric problems led, in 2007, to revisions to the existing Mental Health Act. Following these changes, under a (euphemistically termed) ‘Community Treatment Order,’ patients under section could be compelled to continue taking psychiatric drugs after their discharge or be forcibly returned to hospital. Despite a lack of evidence for any clinical benefits to service users, psychiatry’s deployment of Community Treatment Orders, and compulsion generally, has steadily increased over the last decade.

Typically, mental health legislation across the Western world is developed around two central constructs, each of dubious validity: the presence of a formal ‘mental disorder’ and an evaluation of the level of risk posed, to self and others, by the psychiatric patient. Forced treatment (‘sectioning’) requires no consideration as to whether the individual has the wherewithal to make his or her own decisions, thereby failing to recognise that people suffering high levels of emotional distress often retain the capacity to make informed and rational choices.

Their vulnerability to detention without trial, in the absence of any criminal offence, tars psychiatric patients with a similar status to suspected terrorists. Meanwhile, the state sponsors mental health professionals to implement this legalised discrimination, a task they (for the most part) dutifully fulfill without a murmur of dissent.

The demand for a radical reform of mental health legislation is, I believe, a campaign that would unite the array of critical voices striving for radical alternatives to the currently dominant bio-medical approach to human suffering. A key part of such a mission could be for mental health professionals on this side of the debate — and the formal bodies representing them — to consider a collective policy of non-cooperation (or perhaps something akin to conscientious objection) with implementing the requirements of the Mental Health Act.

Desired alternatives:

– Promotion of alternative legal frameworks that are developed around assessment of the individual’s ability to make their own decisions. Psychiatric treatment does not need to be the subject of special legislation; a unitary law governing non-consensual treatment of both physical and mental health problems is required.

– Development of a Fusion law, as proposed by Szmukler and his colleagues, which would apply consistent ethical principles and would reduce legal discrimination against those suffering emotional difficulties.

Unifying goal 3: Abolition of the Diagnostic and Statistical Manual (DSM) classification system and an end to disease-mongering

For more than half a century the synergistic manoeuvres of psychiatry and the pharmaceutical industry have created a fantastical world of ubiquitous mental illness and chemical cures. Consequently, more and more aspects of human behaviour and emotion are construed as pathological and excessive drug-prescribing is legitimised. A total rejection of the DSM, along with the associated disease-mongering, constitutes a mission that could find favour with all of us critical of Western psychiatry.

Armed with the spurious assumption that the various forms of human suffering and overwhelm are analogous to physical diseases, a committee of the American Psychiatric Association occasionally gather around a table to decide which ‘mental disorders’ will be included in this hugely profitable DSM book. The most recent product (DSM-5) of this largely subjective exercise included 15 more illnesses than its predecessor and an expansion of the criteria indicative of a ‘mood disorder’ — anyone who remains low in mood two weeks after the death of a loved one is now considered to be mentally ill.

Despite these categorisations predicting neither the future course of a ‘mental disorder,’ nor the kinds of intervention that are likely to be helpful , their misleading veneer of scientific respectability ensures that they continue to be influential across research, clinical and political arenas. Although defenders of the DSM system argue that they are an essential aid to communication within the psychiatric world, these classification systems perpetuate the dominance of bio-medical understandings of human distress and the corresponding overuse of drugs, as well as promoting stigma against those so labelled.

Desired alternatives:

– Focus efforts on promoting wellbeing as opposed to the ‘treatment of mental illness.’

– Routine use of non-medical language when describing human suffering and overwhelm.

– Greater emphasis on tacking the causes of distress such as trauma, inequality, discrimination, homelessness, poverty and victimisation.

– Prioritise personal stories and individual formulations in determining the sort of help and support required.

– Strive to understand each individual’s construction of recovery and desired outcomes, while always recognising that each person’s journey will be unique.

– Accept distress as a normal human reaction to adverse life circumstances, rather than a sign of internal pathology.

In summary, this article has addressed the practical question of how those opposed to existing psychiatric practices can pull together to maximize the chance of success in the ongoing struggle for change. Irrespective of what terms we use to describe the movement, the central goal must be the realization of an alternative system for responding to suffering and anguish, radically different from the ‘drug and control’ approach that currently dominates. The success or otherwise of the antipsychiatry movement — or whatever we wish to call it — will ultimately be judged on the achievement of this fundamental objective.

With this in mind, the above represents my attempt to offer a broad manifesto to highlight the areas where those critical of Western psychiatry might join forces to achieve a radical shift in how our society responds to human distress. Is this a framework that all of us on this side of the argument could unite around?