Open Forum: Evolution of the Antipsychiatry Movement Into Mental Health Consumerism

Radical antipsychiatry in the past four decades has changed from an influential international movement dominated by intellectual psychiatrists to an ex-patient consumerist coalition fighting against pharmacological treatment, coercive hospitalizations, and other authoritarian psychiatric practices. This Open Forum article explores the history of the antipsychiatry movement and attempts to define how the movement has evolved.

The antecedents of the antipsychiatry movement can be traced to the early 1950s, when deep divisions were developing between biological and psychoanalytic psychiatrists. Psychoanalytic psychiatry, which had exerted unchallenged control of the profession for decades, endorsed treatment that was subjective and dynamic and that involved protracted psychotherapy. It was being challenged by biological psychiatry, which claimed that psychoanalysis was unscientific, costly, and ineffective.

Conversely, an outcry was mounting against psychiatry's practice of compulsory admission of mental patients to state institutions, where they were coerced into taking high doses of neuroleptic drugs and undergoing convulsive and psychosurgical procedures. The antipsychiatry movement arose as a group of scholarly psychoanalysts and sociologists shaped an organized opposition to what were perceived as biological psychiatry's abuses in the name of science. This protest was joined by a 1960s worldwide counterculture that was already rebelling against all forms of political, sexual, and racial injustice.

The term "antipsychiatry" was first coined in 1967 by the South African psychoanalyst David Cooper ( 1 ) well after the movement was already under way. It was internationally promoted through the efforts of its four seminal thinkers, Michel Foucault in France, R. D. Laing in Great Britain, Thomas Szasz in the United States, and Franco Basaglia in Italy. All four championed the concept that personal reality was independent from any hegemonic definition of normalcy imposed by organized psychiatry.

In Madness and Civilization: A History of Insanity in the Age of Reason ( 2 ), Foucault traced the social context of mental illness and noted that external economic and cultural interests have always defined it. During the Renaissance, madmen were characterized as fools who figured prominently in the writings of Shakespeare and Cervantes. Beginning in the 17th century, madmen were confined and locked away, justified by the state's "imperative of labor." The poor, criminals, and the insane were all isolated as a condemnation of anyone unwilling or unable to compete for gainful employment.

In the early 1800s madmen were separated from prisoners and beggars and forced into hospitals run by medical doctors. Madness was reinvented as a disease, and inhumane treatment was begun. It consisted of classification, custody, and coercion by a psychiatric authority, which operated as an arm of the state, ridding it of unwanted individuals. Psychiatry became "a jurisdiction without appeal … between the police and the courts … a third order of repression" ( 2 ).

While Foucault was writing in France in the early 1960s, R. D. Laing, in England, joined other authors of the period who were describing the social origins of behavior. Fanon ( 3 ) demonstrated how blacks often would fulfill racist stereotypes; Lessing ( 4 ), how women commonly conformed to society's expectation of passivity and femininity; and Goffman ( 5 ), how patients, stripped of normal social responsibilities, developed institutional behavior. Laing promoted the idea that severe mental illness, similarly, had a social causality.

In The Divided Self: An Existential Study in Sanity and Madness ( 6 ), a best-seller in colleges across the United States and Great Britain, Laing noted that a patient with psychosis could be viewed in one of two ways: "One may see his behaviour as 'signs' of a 'disease' [or] one may see his behaviour as expressive of his existence." For Laing, paranoid delusions were not signs of an illness but an understandable reaction to an inescapable and persecutory social order. If Laing was correct, and schizophrenia were not a disease but rather an existential fight for personal freedom, then logic allows that it could be cured through social remediation. Laing, through the Philadelphia Association founded with Cooper in 1965, set up over 20 therapeutic communities throughout England where staff and patients assumed equal status and any medication used was voluntary. A recounting of a seven-week stay in one of these communities was chronicled in the 1972 film Asylum ( 7 ).

Other psychoanalysts were also exploring the social context surrounding mental illness. Thomas Szasz, having recently been appointed to the faculty of the State University of New York, in 1957 wrote his most influential paper, "The Myth of Mental Illness." Over the next three years, it was rejected by at least six psychiatric journals, including the American Journal of Psychiatry , until it was finally accepted for publication in the American Psychologist ( 8 ) in 1960. As the antipsychiatry movement gained momentum, this article became the core of his best-selling book ( 9 ) by the same name and the slogan around which many in the movement rallied.

Because schizophrenia demonstrated no discernible brain lesion, Szasz believed its classification as a disease was a fiction perpetrated by organized psychiatry to gain power. The state, searching for a way to exclude nonconformists and dissidents, legitimized psychiatry's coercive practices. Equating the resulting psychiatry-government collusion with the Spanish Inquisition, Szasz ( 10 ) called it "the single most destructive force that has affected American society within the last 50 years." Such a conspiratorial link between the government and psychiatry was an appealing concept to such counterculture icons as Timothy Leary ( 11 ), who, preceding his termination from Harvard, wrote to Szasz in 1961 that "the Myth of Mental Illness is the most important book in the history of psychiatry … perhaps … the most important book published in the twentieth century."

Citing the principle of "separation of church and state," Szasz argued for a similarly clear division between "psychiatry and state." Otherwise, the state would ultimately corrupt psychiatry for its own purposes, as occurred in Nazi Germany and the Soviet Union. As a preventive measure, Szasz helped launch the Libertarian Party in 1971, and its platform called for a halt to government-psychiatry mind control operations.

Others involved in the antipsychiatry movement were even more condemning. In 1969, Scientology's charismatic founder, L. Ron Hubbard ( 12 ), wrote, "There is not one institutional psychiatrist alive who … could not be arraigned and convicted of extortion, mayhem and murder." Hubbard and Szasz cofounded the still powerful Citizens Commission on Human Rights, which encouraged the arrest and incarceration of psychiatrists for their crimes against humanity.

Alliances were formed with other contemporary activist groups. In May 1970, hundreds in the antipsychiatry movement joined gay activists in forming a human chain barring psychiatrists from entering the American Psychiatric Association's 124th annual meeting. During a similar disruption the following year, gay activist Frank Kameny grabbed the podium and declared war on psychiatry for its DSM classification of homosexuality as a psychiatric disorder. Wanting the protests to stop, the American Psychiatric Association formed a task force, which, by a vote of 58 percent, officially deleted homosexuality as a mental illness in 1973.

Psychiatry's purported abuse of patients was popularized in Kesey's 1962 novel, One Flew Over the Cuckoo's Nest ( 13 ), which contributed to reforms in mental health public policy. David Bazelon, a jurist of the powerful United States Court of Appeals for the District of Columbia, deplored authoritarian psychiatric practices. In 1966, he established in Lake v. Cameron that all psychiatric treatment must be carried out in the least restrictive setting possible. In the early 1970s the antipsychiatry attorney Bruce Ennis created the "Mental Health Bar." Its goal was to completely abolish involuntary commitments or prevent them by making them too arduous to secure. These and other initiatives heralded the release of hundreds of thousands of patients from state hospitals.

Deinstitutionalization in Europe occurred over a decade later. The Italian psychiatrist Franco Basaglia, its leading proponent, while working at the asylum in Trieste, came to believe that mental illness was not a disease but rather an expression of human needs. Over the next decade he personally mobilized an antipsychiatry movement in Italy that culminated in the 1978 Italian National Reform Bill that banned all asylums and compulsory admissions and established community hospital psychiatric units, which were restricted to 15 beds. This reorganization of mental health services in Italy resulted in the "democratic psychiatry movement," wherein hundreds of psychiatric institutions were closed throughout Europe, New Zealand, and Australia, including many in Ireland and Finland, where the highest number of asylum beds were located.

Despite such notable successes and after nearly two decades of prominence, the international antipsychiatry movement began to dramatically diminish in the early 1980s, both in visibility and impact. Organized psychiatry, by addressing some of the movement's key grievances, was able to defuse it to some degree. The adoption of the biopsychosocial model narrowed the gap between analytic and biological practitioners. Neurotransmitter discoveries and schizophrenia twin registries offered support that schizophrenia was at least partially biologically based. As comparison studies failed to support efficacy and as tardive dyskinesia became more apparent, psychiatrists markedly reduced dosages of neuroleptics prescribed. Electroconvulsive therapy and psychosurgery became marginalized as treatments and compulsory commitments came under close judicial scrutiny.

But by far the most important determinant of the movement's demise was its loss of broad-based support. To a great extent, the antipsychiatry movement was derived from its close relationship to other progressive leftist coalitions that, by association and overlapping membership, supported the movement. With the decline of other student, feminist, gay, and black coalitions, the antipsychiatry movement could no longer rely on counterculture support. The radical left, with its utopian vision, was being replaced, worldwide, by an emerging conservative political landscape. Since the antipsychiatry movement's raison d'être was inherently antiestablishment, it, like the other militant movements of the day, was at risk of becoming increasingly irrelevant.

The mental health consumerist movement offered a struggling antipsychiatry coalition the mainstream collaborator it needed for rejuvenation. Since its inception in the early 1900s by former patient Clifford Beers and through organizations such as the Anti-Insane Asylum Society and the National Committee on Mental Hygiene, the consumerist movement had achieved significant international mental health reforms. Its tactics of forming political alliances and lobbying instead of confrontation appealed to conservative politicians who were weary of civil disobedience. The movement's vision of patients helping one another addressed a growing concern over the cost of mental health treatment.

But consumerists considered the antipsychiatry movement as "largely an intellectual exercise of academics" ( 14 ). Consumerists wanted to keep their movement in the hands of prior patients. They had no interest in being led by psychiatrist intellectuals who had done little during the antipsychiatry movement to "reach out to struggling ex-patients" ( 14 ). As a result, as the antipsychiatry movement evolved from being campus based to being patient based, its founders were marginalized as bystanders to a movement they had begun. Appelbaum ( 15 ) in 1994 observed, "Now, more than three decades later, … Szasz, Laing, and their colleagues are no longer fixtures … and … most college and graduate students have never heard of them or their argument that mental illness is a socially derived myth."

With over a half million deinstitutionalized patients to draw from, there was a potential for the new antipsychiatry consumerist coalition to be extensive. Many former patients, angry about the coercive treatment they had received and looking for support and identity, would be ideal carriers of the antipsychiatry message. They joined local consumerist radical groups, and new ex-patient leaders arose. Leonard Frank, founder of Support Coalition International, after undergoing over 80 insulin comas and electroshock treatments, became electroshock therapy's new outspoken critic. Ex-patient Judi Chamberlin, cofounder of the Mental Patients Liberation Front, mobilized the movement with On Our Own: Patient-Controlled Alternatives to the Mental Health System ( 16 ).

The formative years of this movement in the United States saw "survivors" promoting their antipsychiatry, self-determination message through small, disconnected groups, including the Insane Liberation Front, the Mental Patients' Liberation project, the Mental Patient's Liberation Front, and the Network Against Psychiatric Assault. The fragmented networks communicated through their annual Conference on Human Rights and Psychiatric Oppression (held from 1973 to 1985), through the ex-patient-run Madness Network News (from 1972 to 1986), and through the annual "Alternatives" conference funded by the National Institute of Mental Health for mental health consumers (from 1985 to the present). Similar groups arose throughout Canada and, later, Europe, where the name "survivor" brought more public criticism because of its association with the holocaust. The movement searched for a unifying medium through which to integrate.

The growing Internet "global community" offered just such a medium. Numerous radical antipsychiatry Web sites, such as Support Coalition International, Citizens Commission on Human Rights, the Antipsychiatry Coalition, and MindFreedom International, linked antipsychiatry movements in over 30 countries. Their capacity to instantaneously reach millions meant that "despite its modest head count, the consumer/survivor movement … exerted a significant sociopolitical influence on the mental health care system" ( 17 ). By avoiding the antipsychiatry movement flaw of being radicalized without being politicized, radical consumerists continued to maintain informal ties with more conservative consumerist organizations such as the National Alliance for the Mentally Ill in the United States and the Mental Health Foundation in England. Mainstream consumerist groups benefited from such unofficial relationships through increased impact in grassroots lobbying and legislative advocacy efforts.

Such joint efforts exerted a palpable effect. In 1986 the survivor-antipsychiatry-consumerist triumvirate succeeded in getting Congress to mandate independent protection and advocacy programs for people with mental illness in all 50 states. The mission to investigate allegations of patient abuse came with a mandate that at least 60 percent of the membership of the governing advocacy councils be ex-psychiatric patients or their families.

In 2000 the National Council on Disability, an independent federal agency charged with making recommendations to the President and Congress, heard strong antipsychiatry testimony from survivors "describing how people with psychiatric disabilities have been beaten, shocked, isolated, incarcerated, restricted, raped, deprived of food and bathroom privileges, and physically and psychologically abused in institutions." The council concluded that "People with psychiatric disabilities are routinely deprived of their rights in a way no other disability group has been [and] … the manner in which American society treats people with psychiatric disabilities constitutes a national emergency and a national disgrace" ( 18 ).

Radical consumerists were instrumental in getting the United Nations General Assembly to adopt its 1991 Principles for the Protection of Persons With Mental Illness and the Improvement of Mental Health Care. In 2002 the Scientology-funded Commission on Human Rights successfully petitioned the Secretary-General of the United Nations to report annually to the General Assembly on the progress of human rights, including as it relates to persons with mental illness.

Organized psychiatry has found it difficult to have a constructive dialogue with the evolving radical consumerist movement. Consumerist groups are viewed as extremist, having little scientific foundation and no defined leadership. The profession sees them as continually trying to restrict "the work of psychiatrists and care for the seriously mentally ill" ( 17 ). Psychiatry continues to fight antipsychiatry disinformation on the use of involuntary commitment, electroconvulsive therapy, stimulants and antidepressants among children, and neuroleptics among adults.

Conversely, radical consumerists remain disinclined to soften their antipsychiatry stance toward a territorial and biologically oriented profession that, in their view, has profited from patients it neglected and abused. Seeing themselves as "the last minority" ( 17 ), unfairly stigmatized by psudoscientific classification, and denied self-determination, they will undoubtedly continue to play an assertive role in the delivery of mental health services worldwide.