Jun 01, 2006 01:00 AM

Abstract
 
This essay reviews the history and evolution of the antipsychiatrymovement. Radical antipsychiatry over several decades has changed froman antiestablishment campus-based movement to a patient-basedconsumerist movement. The antecedents of the movement are traced to acrisis in self-conception between biological and psychoanalyticpsychiatry occurring during a decade characterized by other radicalmovements. It was promoted through the efforts of its four seminalthinkers: Michel Foucault in France, R. D. Laing in Great Britain,Thomas Szasz in the United States, and Franco Basaglia in Italy. Theychampioned the concept that personal reality and freedom wereindependent of any definition of normalcy that organized psychiatrytried to impose. The original antipsychiatry movement made majorcontributions but also had significant weaknesses that ultimatelyundermined it. Today, antipsychiatry adherents have a broader base andno longer focus on dismantling organized psychiatry but look to promoteradical consumerist reform.

[Essay:]

Radical antipsychiatry in the past four decades has changed from aninfluential international movement dominated by intellectualpsychiatrists to an ex-patient consumerist coalition fighting againstpharmacological treatment, coercive hospitalizations, and otherauthoritarian psychiatric practices. This Open Forum article exploresthe history of the antipsychiatry movement and attempts to define howthe movement has evolved.

The antecedents of the antipsychiatry movement can be traced to theearly 1950s, when deep divisions were developing between biological andpsychoanalytic psychiatrists. Psychoanalytic psychiatry, which hadexerted unchallenged control of the profession for decades, endorsedtreatment that was subjective and dynamic and that involved protractedpsychotherapy. It was being challenged by biological psychiatry, whichclaimed that psychoanalysis was unscientific, costly, and ineffective.

Conversely, an outcry was mounting against psychiatry’s practice ofcompulsory admission of mental patients to state institutions, wherethey were coerced into taking high doses of neuroleptic drugs andundergoing convulsive and psychosurgical procedures. The antipsychiatrymovement arose as a group of scholarly psychoanalysts and sociologistsshaped an organized opposition to what were perceived as biologicalpsychiatry’s abuses in the name of science. This protest was joined bya 1960s worldwide counterculture that was already rebelling against allforms of political, sexual, and racial injustice.

The term “antipsychiatry” was first coined in 1967 by the SouthAfrican psychoanalyst David Cooper (1) well after the movement wasalready under way. It was internationally promoted through the effortsof its four seminal thinkers, Michel Foucault in France, R. D. Laing inGreat Britain, Thomas Szasz in the United States, and Franco Basagliain Italy. All four championed the concept that personal reality wasindependent from any hegemonic definition of normalcy imposed byorganized psychiatry.

In Madness and Civilization: A History of Insanity in the Age ofReason (2), Foucault traced the social context of mental illness andnoted that external economic and cultural interests have always definedit. During the Renaissance, madmen were characterized as fools whofigured 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 unwillingor unable to compete for gainful employment.

In the early 1800s madmen were separated from prisoners and beggarsand forced into hospitals run by medical doctors. Madness wasreinvented as a disease, and inhumane treatment was begun. It consistedof classification, custody, and coercion by a psychiatric authority,which operated as an arm of the state, ridding it of unwantedindividuals. 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 weredescribing the social origins of behavior. Fanon (3) demonstrated howblacks often would fulfill racist stereotypes; Lessing (4), how womencommonly conformed to society’s expectation of passivity andfemininity; and Goffman (5), how patients, stripped of normal socialresponsibilities, developed institutional behavior. Laing promoted theidea 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 GreatBritain, Laing noted that a patient with psychosis could be viewed inone of two ways: “One may see his behaviour as ‘signs’ of a ‘disease'[or] one may see his behaviour as expressive of his existence.” ForLaing, paranoid delusions were not signs of an illness but anunderstandable reaction to an inescapable and persecutory social order.If Laing was correct, and schizophrenia were not a disease but ratheran existential fight for personal freedom, then logic allows that itcould be cured through social remediation. Laing, through thePhiladelphia Association founded with Cooper in 1965, set up over 20therapeutic communities throughout England where staff and patientsassumed equal status and any medication used was voluntary. Arecounting of a seven-week stay in one of these communities waschronicled in the 1972 film Asylum (7).

Other psychoanalysts were also exploring the social contextsurrounding mental illness. Thomas Szasz, having recently beenappointed to the faculty of the State University of New York, in 1957wrote his most influential paper, “The Myth of Mental Illness.” Overthe next three years, it was rejected by at least six psychiatricjournals, including the American Journal of Psychiatry, until it wasfinally accepted for publication in the American Psychologist (8) in1960. As the antipsychiatry movement gained momentum, this articlebecame the core of his best-selling book (9) by the same name and theslogan around which many in the movement rallied.

Because schizophrenia demonstrated no discernible brain lesion,Szasz believed its classification as a disease was a fictionperpetrated by organized psychiatry to gain power. The state, searchingfor a way to exclude nonconformists and dissidents, legitimizedpsychiatry’s coercive practices. Equating the resultingpsychiatry-government collusion with the Spanish Inquisition, Szasz(10) called it “the single most destructive force that has affectedAmerican society within the last 50 years.” Such a conspiratorial linkbetween the government and psychiatry was an appealing concept to suchcounterculture icons as Timothy Leary (11), who, preceding histermination from Harvard, wrote to Szasz in 1961 that “the Myth ofMental Illness is the most important book in the history of psychiatry… perhaps … the most important book published in the twentiethcentury.”

Citing the principle of “separation of church and state,” Szaszargued for a similarly clear division between “psychiatry and state.”Otherwise, the state would ultimately corrupt psychiatry for its ownpurposes, as occurred in Nazi Germany and the Soviet Union. As apreventive measure, Szasz helped launch the Libertarian Party in 1971,and its platform called for a halt to government-psychiatry mindcontrol operations.

Others involved in the antipsychiatry movement were even morecondemning. 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 onHuman Rights, which encouraged the arrest and incarceration ofpsychiatrists for their crimes against humanity.

Alliances were formed with other contemporary activist groups. InMay 1970, hundreds in the antipsychiatry movement joined gay activistsin forming a human chain barring psychiatrists from entering theAmerican Psychiatric Association’s 124th annual meeting. During asimilar disruption the following year, gay activist Frank Kamenygrabbed the podium and declared war on psychiatry for its DSMclassification of homosexuality as a psychiatric disorder. Wanting theprotests to stop, the American Psychiatric Association formed a taskforce, which, by a vote of 58 percent, officially deleted homosexualityas a mental illness in 1973.

Psychiatry’s purported abuse of patients was popularized in Kesey’s1962 novel, One Flew Over the Cuckoo’s Nest (13), which contributed toreforms in mental health public policy. David Bazelon, a jurist of thepowerful United States Court of Appeals for the District of Columbia,deplored authoritarian psychiatric practices. In 1966, he establishedin Lake v. Cameron that all psychiatric treatment must be carried outin the least restrictive setting possible. In the early 1970s theantipsychiatry attorney Bruce Ennis created the “Mental Health Bar.”Its goal was to completely abolish involuntary commitments or preventthem by making them too arduous to secure. These and other initiativesheralded the release of hundreds of thousands of patients from statehospitals.

Deinstitutionalization in Europe occurred over a decade later. TheItalian psychiatrist Franco Basaglia, its leading proponent, whileworking at the asylum in Trieste, came to believe that mental illnesswas not a disease but rather an expression of human needs. Over thenext decade he personally mobilized an antipsychiatry movement in Italythat culminated in the 1978 Italian National Reform Bill that bannedall asylums and compulsory admissions and established communityhospital psychiatric units, which were restricted to 15 beds. Thisreorganization of mental health services in Italy resulted in the”democratic psychiatry movement,” wherein hundreds of psychiatricinstitutions were closed throughout Europe, New Zealand, and Australia,including many in Ireland and Finland, where the highest number ofasylum beds were located.

Despite such notable successes and after nearly two decades ofprominence, the international antipsychiatry movement began todramatically diminish in the early 1980s, both in visibility andimpact. Organized psychiatry, by addressing some of the movement’s keygrievances, was able to defuse it to some degree. The adoption of thebiopsychosocial model narrowed the gap between analytic and biologicalpractitioners. Neurotransmitter discoveries and schizophrenia twinregistries offered support that schizophrenia was at least partiallybiologically based. As comparison studies failed to support efficacyand as tardive dyskinesia became more apparent, psychiatrists markedlyreduced dosages of neuroleptics prescribed. Electroconvulsive therapyand psychosurgery became marginalized as treatments and compulsorycommitments came under close judicial scrutiny.

But by far the most important determinant of the movement’s demisewas its loss of broad-based support. To a great extent, theantipsychiatry movement was derived from its close relationship toother progressive leftist coalitions that, by association andoverlapping membership, supported the movement. With the decline ofother student, feminist, gay, and black coalitions, the antipsychiatrymovement could no longer rely on counterculture support. The radicalleft, with its utopian vision, was being replaced, worldwide, by anemerging conservative political landscape. Since the antipsychiatrymovement’s raison d’être was inherently antiestablishment, it, like theother militant movements of the day, was at risk of becomingincreasingly irrelevant.

The mental health consumerist movement offered a strugglingantipsychiatry coalition the mainstream collaborator it needed forrejuvenation. Since its inception in the early 1900s by former patientClifford Beers and through organizations such as the Anti-Insane AsylumSociety and the National Committee on Mental Hygiene, the consumeristmovement had achieved significant international mental health reforms.Its tactics of forming political alliances and lobbying instead ofconfrontation appealed to conservative politicians who were weary ofcivil disobedience. The movement’s vision of patients helping oneanother addressed a growing concern over the cost of mental healthtreatment.

But consumerists considered the antipsychiatry movement as “largelyan intellectual exercise of academics” (14). Consumerists wanted tokeep their movement in the hands of prior patients. They had nointerest in being led by psychiatrist intellectuals who had done littleduring the antipsychiatry movement to “reach out to strugglingex-patients” (14). As a result, as the antipsychiatry movement evolvedfrom being campus based to being patient based, its founders weremarginalized 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 … mostcollege and graduate students have never heard of them or theirargument 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 coalitionto be extensive. Many former patients, angry about the coercivetreatment they had received and looking for support and identity, wouldbe ideal carriers of the antipsychiatry message. They joined localconsumerist radical groups, and new ex-patient leaders arose. LeonardFrank, founder of Support Coalition International, after undergoingover 80 insulin comas and electroshock treatments, became electroshocktherapy’s new outspoken critic. Ex-patient Judi Chamberlin, cofounderof the Mental Patients Liberation Front, mobilized the movement with OnOur 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 messagethrough small, disconnected groups, including the Insane LiberationFront, the Mental Patients’ Liberation project, the Mental Patient’sLiberation Front, and the Network Against Psychiatric Assault. Thefragmented networks communicated through their annual Conference onHuman 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 NationalInstitute of Mental Health for mental health consumers (from 1985 tothe present). Similar groups arose throughout Canada and, later,Europe, where the name “survivor” brought more public criticism becauseof its association with the holocaust. The movement searched for aunifying medium through which to integrate.

The growing Internet “global community” offered just such a medium.Numerous radical antipsychiatry Web sites, such as Support CoalitionInternational, Citizens Commission on Human Rights, the AntipsychiatryCoalition, and MindFreedom International, linked antipsychiatrymovements in over 30 countries. Their capacity to instantaneously reachmillions meant that “despite its modest head count, theconsumer/survivor movement … exerted a significant sociopoliticalinfluence on the mental health care system” (17). By avoiding theantipsychiatry movement flaw of being radicalized without beingpoliticized, radical consumerists continued to maintain informal tieswith more conservative consumerist organizations such as the NationalAlliance for the Mentally Ill in the United States and the MentalHealth Foundation in England. Mainstream consumerist groups benefitedfrom such unofficial relationships through increased impact ingrassroots lobbying and legislative advocacy efforts.

Such joint efforts exerted a palpable effect. In 1986 thesurvivor-antipsychiatry-consumerist triumvirate succeeded in gettingCongress to mandate independent protection and advocacy programs forpeople with mental illness in all 50 states. The mission to investigateallegations of patient abuse came with a mandate that at least 60percent of the membership of the governing advocacy councils beex-psychiatric patients or their families.

In 2000 the National Council on Disability, an independent federalagency charged with making recommendations to the President andCongress, heard strong antipsychiatry testimony from survivors”describing how people with psychiatric disabilities have been beaten,shocked, isolated, incarcerated, restricted, raped, deprived of foodand bathroom privileges, and physically and psychologically abused ininstitutions.” The council concluded that “People with psychiatricdisabilities are routinely deprived of their rights in a way no otherdisability group has been [and] … the manner in which Americansociety treats people with psychiatric disabilities constitutes anational emergency and a national disgrace” (18).

Radical consumerists were instrumental in getting the UnitedNations General Assembly to adopt its 1991 Principles for theProtection of Persons With Mental Illness and the Improvement of MentalHealth Care. In 2002 the Scientology-funded Commission on Human Rightssuccessfully petitioned the Secretary-General of the United Nations toreport annually to the General Assembly on the progress of humanrights, including as it relates to persons with mental illness.

Organized psychiatry has found it difficult to have a constructivedialogue with the evolving radical consumerist movement. Consumeristgroups are viewed as extremist, having little scientific foundation andno defined leadership. The profession sees them as continually tryingto restrict “the work of psychiatrists and care for the seriouslymentally ill” (17). Psychiatry continues to fight antipsychiatrydisinformation on the use of involuntary commitment, electroconvulsivetherapy, stimulants and antidepressants among children, andneuroleptics among adults.

Conversely, radical consumerists remain disinclined to soften theirantipsychiatry stance toward a territorial and biologically orientedprofession that, in their view, has profited from patients it neglectedand abused. Seeing themselves as “the last minority” (17), unfairlystigmatized by psudoscientific classification, and deniedself-determination, they will undoubtedly continue to play an assertiverole in the delivery of mental health services worldwide.

Footnotes
 
Dr. Rissmiller is affiliated with the Department of Psychiatry,School of Osteopathic Medicine, University of Medicine and Dentistry ofNew Jersey, Cherry Hill, New Jersey 08002 (e-mail, rissmidj@umdnj.edu). Mr. Rissmiller is attending Harvard College in Cambridge,Massachusetts.

References
 
1 Cooper D: Psychiatry and Anti-Psychiatry. London, Tavistock Publications, 1967

2 Foucault M: Madness and Civilization: A History of Insanity in the Age of Reason. New York, Random House, 1965

3 Fanon F: The Wretched of the Earth. New York, Grove Press, 1963

4 Lessing DM: The Golden Notebook. New York, Simon and Schuster, 1962

5 Goffman E: Asylums: Essays on the Social Situation of Mental Patients and Other Inmates. New York, Anchor Books, 1961

6 Laing RD: The Divided Self: An Existential Study in Sanity and Madness. Harmondsworth, England, Penguin, 1960

7 Robinson P (director): Asylum. Kino Video, 1972

8 Szasz TS: The myth of mental illness. American Psychologist 15:113–118,1960

9 Szasz TS: The Myth of Mental Illness: Foundations of a Theory of Personal Conduct. New York, Hoeber-Harper, 1961

10 Szasz TS: The Manufacture of Madness: A Comparative Study of theInquisition and the Mental Health Movement. New York, Harper and Row,1970

11 Leary T: A letter from Timothy Leary, Ph.D., July 17, 1961. Available at www.szasz.com/leary.html

12 Hubbard LR: Crime and psychiatry, June 23, 1969. Available at http://freedom. lronhubbard.org/page080.htm

13 Kesey K: One Flew Over the Cuckoo’s Nest. New York, Viking Press, 1962

14 Chamberlin J: The ex-patients’ movement: where we’ve been and where we’re going. Journal of Mind and Behavior 11:323–336,1990

15 Appelbaum PS: Almost a Revolution: Mental Health Law and the Limits of Change. New York, Oxford University Press, 1994

16 Chamberlin J: On Our Own: Patient-Controlled Alternatives to the Mental Health System. New York, Hawthorne, 1978

17 Satel SL, Redding RE: Sociopolitical trends in mental healthcare: the consumer/survivor movement and multiculturalism, in Kaplanand Sadock’s Comprehensive Textbook of Psychiatry, 8th ed. Edited bySadock BJ, Sadock VA. Philadelphia, Pa, Lippincott Williams andWilkins, 2005

18 Bristo M: From Privileges to Rights: People Labeled WithPsychiatric Disabilities Speak for Themselves. Washington, DC, NationalCouncil on Disability, Jan 20, 2000

– end –