Letter

"Antipsychiatry" and "Consumerism": Perspectives and Definitions

To the Editor: I read the Rismillers' Open Forum, "Evolution of the Antipsychiatry Movement Into Mental Health Consumerism," in the June issue and the follow-up letters to the editor that were published in the August issue with special interest because I have taught and researched this topic for many years ( 1 ). The Rismillers trace the history of the antipsychiatry movement, although they misinterpret and overstate its demise. However, their emphasis on mental health "consumerism" and numerous historical and factual errors about the "ex-mental patient" self-help movement are the primary concerns of their critics. The debate hinges on individual versus social perspectives, a dichotomy that highlights the individualistic, pro-psychiatry bias of the Rismillers. Their critics reveal a social "antipsychiatry" perspective, despite some of their claims to the contrary. Also, an underlying problem is the failure of all parties to define key terms. [A bibliography documenting statements made in this letter and providing additional sources for interested readers is available online at ps.psychiatryonline.org.]

The Rismillers discuss "mental health consumerism" and project a psychologistic perspective that underestimates the size of the ex-patient movement and ignores its preference for the "survivor" label over the "consumer" label ( 2 ). Their critics understate the radical nature of the ex-patient movement. In fact, more than 60 percent of ex-patient groups support antipsychiatry beliefs and consider themselves to be "psychiatric survivors." Many in the "mad liberation" movement believe they are victims of psychiatric treatments that harmed them. Patients are not "consumers" choosing from a menu of psychiatric services, like shoppers at a cafeteria deciding what to have for lunch. The victim-survivor perspective of ex-patient groups promotes "alternatives" to psychiatry. They seek empowerment through group activism, what they call "taking the 13th step," toward a sociopolitical understanding of the problems of living similar to the perspectives of Szasz and Foucault.

The essence of the antipsychiatry perspective is its opposition to involuntary "treatment." The idea of "treating" someone against his or her will, whether by psychoanalysis or chemotherapy, is considered a non sequitur. Accordingly, the Rismillers are more pro-psychiatry and their critics are more antipsychiatry in their perspectives. The Rismillers correctly characterize antipsychiatry as evolving "from being campus based to being patient based" as it morphed into the grassroots activism of the ex-patient movement. However, their argument that the antipsychiatry movement evolved into the ex-patient movement, as a necessary and sufficient "cause," cannot be known. Clearly, the founders of the antipsychiatry movement are often cited as revered heroes by participants in the emerging ex-patient movement, but this does not verify a direct causal connection between the two.

Antipsychiatry promotes skepticism about the concept of "mental illness" as disease. Without carefully defining terms, the Rismillers suggest that antipsychiatry dwindled because scientific advances regarding the nature of mental illness allowed psychiatry to address key grievances of its critics. However, antipsychiatry and the ex-patient movement have always argued that brain disease is what neurologists diagnose and treat, and there is little evidence of physical lesions in the brain that constitute a distinct class of "psychiatric" diseases.

The antipsychiatry and ex-patient movements believe that alternative views of reality are sociocultural phenomena, not "mental illnesses." The Rismillers argue, by contrast, that schizophrenia is at least "partially biologically based," gaining support from neurotransmitter research, twin studies, and psychopharmacological advances. However, one extensive review of research on the cause of schizophrenia analyzed 1,046 studies published between 1991 and 1995 and concluded that the science does not support a unitary cause that correlates with an underlying physical lesion ( 3 ). While most research concentrates on biochemical and genetic causes, these studies present the weakest findings in the literature, leaving the disease hypothesis unsupported.

The Rismillers ignore the extensive literature questioning the scientific evidence for "blaming the brain" and the use of psychotropic drugs or electroshock, genetic theories of mental illness and twin studies of schizophrenia, and the reliability of the DSM, which is so popular in psychiatry today ( 4 ). This literature is well known within the ex-patient movement. Far from explaining the demise of antipsychiatry, it rationalizes the movement by providing a perspective of scientific support for its reformist stance vis-à-vis psychiatry. It also helps explain the expansion of the ex-patient movement, which was recently estimated at 7,467 groups comprising 41,363 members ( 5 ).

Given the extensive critical literature on the concept of "mental illness" and the size of the ex-patient movement, the objective observer might conclude that psychiatry is less scientific and more political than the Rismillers suggest and that the ex-patient movement is more scientific, more antipsychiatry, and a more important social movement than most people understand it to be. Acknowledging different perspectives and carefully defining terms may help clarify this debate.