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Peter Stastny / Peter Lehmann (Eds.)
Alternatives beyond psychiatry is a welcome breath of fresh air. In its pages, 61 authors from around the world (mainly Europe and North America) describe initiatives, projects and personal strategies that challenge traditional approaches. It will be thought-provoking and inspirational reading for anyone interested in innovative responses to madness. The shortcomings of biomedical psychiatry have been much explored and this book does not uncover new territory in this respect. Familiar messages are hammered home around central issues like coercion, diagnostic systems and over-reliance on psychiatric medication. There are two passionate personal statements against the psychiatric enterprise by Kate Millett and Dorothea Buck, whose 70 years experience of the German psychiatric system includes compulsory sterilisation, and an interesting short (too short) piece by Pat Bracken about the need to move away from paradigms and models entirely. But at the heart of Alternatives beyond psychiatry, and what makes it such a valuable resource, are the many chapters describing actual alternatives. A few of these have attracted attention in recent years and may already be known to some readers, but a large number have received little coverage and will be hardly known outside their own countries. The editors have done a great service in drawing all this information together. The alternatives included cover a huge range, from crisis provision and Hearing Voices groups to service user-led research, personal ombudsmen and advance directives. Perhaps inevitably with so many contributors, the quality of writing is variable and I found one or two chapters quite difficult to digest. It is not easy to compress the description of innovative work into one short chapter and I sometimes felt I was not being given enough relevant information to really appreciate a new approach. On the other hand, there are many excellent summaries. I thought the chapters 'Intervoice: Accepting and making sense of hearing voices' and on 'Soteria: A treatment model and A Reform Movement in Psychiatry' were particularly good. There is so much positive practice and experience captured in this book that it is impossible not to feel encouraged about the possibilities for a better way forward. Nevertheless, the editors are quite downbeat about the overall impact of alternatives, admitting in the final chapter: 'Since there are currently no widely encompassing alternatives available that offer humane help, psychiatric ex-users and survivors must learn to make the best of the existing services.' This is probably a realistic judgement. On the other hand, Alternatives beyond psychiatry is an excellent argument and blueprint for a continuing effort to construct alternatives. If you are making a list of important mental health titles for 2008, this one should certainly be on it.
If you accept the medical model approach to mental health doesn't work, you may well have been asked: 'But what would you replace it with?' Opening and closing with impassioned arguments against the psychiatric system, this thought-provoking and exhaustive anthology, featuring 61 different authors from many different countries, looks at alternatives to psychiatry and its medical model approach. It describes a whole range of creative approaches to mental health and recovery that are about the efficacy of empowerment, support and cultural sensitivity, of inspiring hope and offering choice, information, self-determination, advocacy, and the possibility that mental health workers can create trusting relationships with their clients. One of its many strengths is that it offers so many ways forward. It concentrates on the practicalities, reporting real, live projects and groups, what they have achieved and the challenges they've faced. It offers individual stories of how people have coped on their own, outside of the psychiatric system. It even includes contributions on using the law to challenge, for example, coercive and forced treatment and the failure to implement advance directives. What could easily have been a disjointed collection of articles is skillfully edited into a narrative for radical change. It works on several levels, whether as a compendium of imaginative ideas and first-person stories, a toolbox of alternatives to psychiatry, or as a summation of the kind of support most service users and survivors would prefer to receive from the mental health system. If read by enough people in a position to make a real difference, it has the potential to radically reform – even revolutionise – mental health care in this country. As such, it is one of the most important books on mental health to have come out in the last decade.
I am finally getting round to writing a short review of this excellent book that was sent to me last year by a German based publisher called Peter Lehmann. Peter is a ex-service user and activist who has taken the publishing route as a way of inspiring change through stories and writing. He has also been very active in the European Network of (ex) Users and Survivors of Psychiatry (ENUSP). The book is a series of chapters written by a mix of mental health authors. Some are professionals while others are service users. All share a fundamental perspective that the user voice is essential to the development and delivery of decent services. The book describes a series of different approaches that can support mental health service users towards recovery and challenge discrimination, unemployment and low income. Standout chapters include those by my friends at Bradford University on mental health, culture and ethnicity and a series of chapters on the power and benefits of self-help. The writing is accessible with a good mix of personal stories and case studies combined with more academic references. It provides some inspirational examples and well as vivid descriptions of the barriers and difficulties people face as they claim their rights. What I particularly like is that the book addresses a full range of diversity issues including gender, culture, sexuality and disability without it feeling like an after thought or tokenism. Given the range of different authors – 61 in total – even if there are certain ones who you do not agree with, there are plenty of others that will resonante and also there are new authors and mental health activists to be introduced to for the first time in the pages. Highly recommended!
This marvellous collection brings together innovative alternatives to psychiatry from different parts of the world. It will stimulate new connections between those who are struggling to speak about experiences of abuse at the hands of those who claim to understand and 'cure' them. There are some intriguing common themes that emerge as we read about initiatives like Soteria, Hotel Magnus Stenbock or The Windhorse Project (to name but three that get an airing here). There is an assumption that 'psychotherapy' of some kind can be counterposed to 'psychiatry', and that genuine psychotherapeutic work is in the good place, beyond bad psychiatry. Each brief scattered mention of Freud in the book, for example, is positive, and quasi-psychodynamic notions jostle alongside humanist perspectives. There is a further assumption that appears in the description of these and other organisations (ranging from Icarus to the Berlin Runaway House to La Cura), which is that this therapeutic work should be conducted in a way that brings people together – even perhaps in some kind of therapeutic community – rather than working with each person individually. There are, of course, tensions between the strategies that are adopted in different cultures. So, for example, the Open Dialogue initiative in Finland works on the assumption that contributions should be tailored to an evolving discussion (and so here the community ethos is very strong), whereas the Law Project for Psychiatric Rights in the United States appeals to individuals to assert their power to seek compensation for wrongs they have suffered at the hands of the psychiatric system. One thing that is striking about the collection is how people faced with psychiatry have often had to reinvent their critique of the medical model in ways that are suited to particular political-cultural circumstances but in ways which also enable them to forge a common cause that is increasingly internationalist. Medical psychiatry has for sure been one of the forces of globalisation, and its proponents have been keen to use 'cross-cultural' research to reinforce its claims to find universal underlying disease entities. This book shows that radical non-psychiatric approaches to suffering are also now able to turn diversity of experience from apparent weakness into strength. Readers can follow the links from the Lehmann website to access debates in and across the various groups that are represented in the book (at www.peter-lehmann-publishing.com) and those debates will no doubt be augmented by the voices of groups that are fighting on the same ground who are not directly involved in this edition. The disclaimers at the beginning of the book about the liability of contributors for harm that might arise from readers coming off medication highlights an issue that is hinted at in different chapters but is not tackled head-on; the conditions in which we try to go 'beyond psychiatry' today are now circled by legal procedures which mostly favour medical psychiatry. But, this book shows that there are ways out. At 431 pages, this sprawling compendium will be an invaluable resource for all those building alliances for a world without psychiatry.
It seems, as if countries that have adopted the modern drug-based paradigm of psychiatric care have, in the past 50 years, experienced a great surge in the number of people disabled by mental disorders. Accordingly, it would appear that we desperately need to reflect on alternatives to this failed paradigm of care. Although in its present form issues dealing with values, meanings, relationships and power are not ignored, these always seem to be secondary to the more important technical aspects of mental health. Indeed, it only tends to underscore the centrality of "experts." In spite of the fact that service (ex-) users and survivors might be consulted and invited to comment on the interventions and the research connected with the reigning paradigm of care, they are nonetheless always recipients of expertise generated elsewhere. In contrast, the recovery agenda, as Pat Bracken puts it in a paper in this book, presents a radical challenge, since it reorients our thinking about mental health completely. It foregrounds issues that have to do with power and relationships, contexts and meanings, values and priorities, which now become primary. Although such an agenda does not reject or deny the reigning role of therapy, services, research and, in some instances, even drugs, it does work to render them all secondary. Indeed, its most radical implication is the fact that when it comes to issues having to do with values, meanings and relationships, it is the (ex-) users or survivors themselves, who are the most knowledgeable and informed. In other words, when it comes to the recovery agenda, they are the real experts. This then is the basic theme of this fascinating new book. After a very short first part on why psychiatry hurts more than it helps – containing a personal report by the 91 year old activist Dorothea Buck-Zerchin, who describes her experience of what she calls 70 years of coercion in psychiatric institutions, as well as a paper by Kate Millett, which focuses on the question of legal rights and the mental health system – the long second part takes up approximately half the book in its discussion of present-day actual alternatives to psychiatry. Its first section describes the concrete strategies of individual (ex-) users and survivors, with or without professional support, and demonstrates that the individual paths taken in order to manage mental crises without ending up in a psychiatrist's office are extremely varied. All fourteen personal reports presented here are deliberately positive, since it is meant to show that it is possible – at least for some – to recover their mental equilibrium using the personal resources at hand and uniquely tackling their problems with at times rather simple and reasonable methods. The second section, which deals with concrete examples of organized (ex-) user and survivor self-help, leads off with Wilma Boevink's paper on the TREE program in the Netherlands, whose underlying principle is that an important element in recovery from long-term mental distress is to develop and pass on narratives. In other words, developing one's own narrative and comparing it with the narratives of other (ex-) users and survivors of psychiatry is the beginning of building experiential knowledge. Of most interest to this reader in this section, however, were the reports on the Hearing Voices movement. Hannelore Klafki's paper on how voices accompanied her throughout her life and how she managed to cope with them to lead a normal life was quite moving. Following up, Romme and Escher describe INTERVOICE, the international network, the basic assumption of which is that accepting and making sense of voices is a much more helpful alternative for recovering from the distress associated with voice hearing. Hearing voices in itself, they point out, is not a sign of mental illness, but it is quite possible to become ill and a psychiatric patient, when one cannot cope with them and the problems laying at their roots. Persons who hear voices and have become ill tend to show a different relationship with their voices than do persons who hear voices and do not become psychiatric patients. Accepting the voices means realizing that the experience of voice hearing is real, and making sense of them suggests that the voices are not something crazy, but have a purpose in helping to learn to cope with life's problems. In another paper, Rufus May, after describing his own struggle with mental crises, discusses the unusual beliefs movement. For example, he reports on the Beyond Belief Network, which aims to help people to cope with unusual beliefs that might be termed delusions by mental health professionals. There are many people, he says, who have beliefs that meet the criteria for delusions, yet who are living successful lives with no contact with psychiatry. The difference between them and those who receive mental health services is whether the individuals involved can cope with their beliefs, and whether they are distressed or preoccupied by them. This way of thinking about unusual beliefs, then, follows from the main concept of the Hearing Voices movement, which states that each person should be able to choose how best to understand his or her own reality and that acceptance, as already mentioned, is an important stage in gaining back the power to manage one's experiences. The third section then goes on to report on alternative models of professional support. In it, the editors Stastny and Lehmann's long paper on Soteria – the treatment model introduced by Loren Mosher in the early 1970s – was to me one of the most informative in the book. After describing Mosher's original model in detail, they discuss the dissemination and replicability of the Soteria approach, list the catalogue of crucial elements that must be in place before a program can call itself Soteria, and soberly give a current assessment and outlook with respect to the model's future, stating there is a risk that Soteria development might come to a complete halt, or even gradually recede. In this section there are also papers on a user-controlled house, the Hotel Magnus Stenbock in Sweden; the Windhorse Project in Boulder, Colorado, Nova Scotia and Vienna, based on Podvoll's working model of psychosis; the Crisis Hostel Project in Ithaca, New York; the Berlin Runaway House; the Second Opinion Society in the Yukon; Trauma-informed Peer Run Crisis Alternatives; La Cura in Sicily; and the Open Dialogue in Finland The third part focuses on general and specific beneficiaries of alternative approaches, that is, on certain subgroups of people with mental health problems. For example, Philip Thomas and Salma Yasmeen's paper presents a conceptual critique of mental health theory and practice to help understand the problems that Western psychiatry poses for people from non-Western cultures or for those in the black and minority ethnic communities. Bruce Levine's paper on managing troubled children and teens without using psychiatric drugs analyses the ten most common sense causes and solutions and is most interesting. In another article, Erich Schützendorf considers the development of a person with dementia not as a pathological alteration, but rather as an expression of individualistic behavior, which makes a respectful encounter possible, offering many concrete examples to prove his point. Psychiatric (ex-) users and survivors, as is known, have been highly skeptical of family involvement in the recovery movement, and have often felt both the controlling and paternalistic experience of not only their own families, but also those of large family advocacy organizations. Dealing with this issue, Karyn Baker contributes a paper on the Family Outreach and Response Program (FOR) in Toronto, which is based on the belief that families can be exceedingly helpful in their relative's recovery when given proper education, support and skills based on a critical recovery perspective. Finally, this section also contains a paper by Guy Holmes and Geoff Hardy on the means of breaking what the authors call the shame cycle, especially in homosexual men. Part four, which this reviewer particularly enjoyed, examines the problem of realizing the alternatives and the humane forms of treatment discussed earlier. It centers on the potential strategies for promoting and disseminating such alternatives and for achieving human rights for mental patients. It is stressed, however, that implementation remains a most difficult undertaking, because the pharmaceutical industry, the health insurance companies, the hospitals and other institutions of authority – banded together with the psychiatric profession – have more or less succeeded in keeping effective alternative projects deprived of funding opportunities. Three articles in this part (as well as one earlier by Miriam Krücke) treat of the manner in which psychiatric patients can legally protect themselves and/or fight for their rights. Two of these focus on the issue of the advance directive, which can be used to assert and sustain self-determination in situations, where people are no longer able to express their will, or are deemed to be lacking the capacity to express their free will. This, then, is a legal instrument designed to preserve the rights of competent individuals to choose or refuse health care. One of these papers, from the American perspective, by Laura Ziegler, is of great interest, especially since she concretely and extensively reports on six cases of varied legal complexity from the USA, showing how patients had to fight to have their psychiatric advance directives accepted by the courts. Of the two other articles that deal with the issue of the legal rights of patients in this part, the one by James Gottstein is a must read. It highlights the work of PsychRights in the USA, which aims at mounting a coordinated litigation campaign in order to substantially reduce forced psychiatric treatment and to create non-coercive, non-medical model alternatives. After some interesting theoretical considerations, Gottstein presents extensive concrete detail on just how a PsychRights campaign works, drawing upon a legal action in Alaska as his primary example. The other paper by Peter Rippmann describes the work of PSYCHEX in Switzerland, which also has taken up the legal fight to free patients incarcerated against their will. David Oaks's paper on MindFreedom International is another high point of the book, in which he calls for a non-violent revolution of freedom, equality, truth and human rights throughout the entire mental health system, the unfair influence of the psychiatric drug industry adding to these human rights violations. He points out that drug corporations use fraud, force and fear to violate the human rights of clients, that they have manipulated the media, advertising and research to convince the public and mental health professionals that those with mental health problems have a chemical imbalance, and that they also use fraud by routinely covering up any information that their products might be harmful and can even kill. Forced drugging is growing, Oaks insists, and psychiatric drug companies fund organizations that lobby the government to make it easier to force the products they manufacture into customers. Moreover, fear is used to show that there is no alternative to force and drugs. In light of this, there ought to be a full range of voluntary, humane, safe options and alternatives offered to all who choose to use them. This Western style mental health system, he says, is often called a "medical model," but more accurately ought to be called the "domination model", since its main effect is to squeeze out all other options from mental health care. Another paper in this section by Ahern et al reports on INTAR, the International Network Toward Alternatives and Recovery, founded in 2003, which is dedicated to advancing the knowledge and availability of alternative approaches for individuals experiencing severe mental distress. Quite characteristic of many alternatives, they point out, is that they often remain the sole example of their generally quite successful approach, but with INTAR there is the possibility that such individual efforts will cross-fertilize and these positive results will become disseminated to a wider audience. In their paper Peter Lehmann and Maths Jesperson describe how (ex-) users and survivors of psychiatry are presently organized and how they cooperate internationally, with a particular emphasis on the role that the internet plays in reaching their goals. Rounding out this part of the book, there are articles on the system of the personal ombudsman in Skåne, Sweden; on user-led research, which emphasizes the value of personal experience in knowledge creation in order to develop an evidence base for alternative approaches; and on the Distress Awareness Training Agency (DATA), which prepares people for (ex-) user or survivor involvement work in England. Part five, the last in the book, takes up the issue of why alternatives to psychiatry are needed. It starts off with Marc Rufer's long article on various aspects of present-day psychiatry's "reductionist vision of humanity", a hard-hitting critique aimed at its diagnostic methods, its therapies and the power that it thereby wields. And then there is Pat Bracken's short, but incisive, analysis of the radical interpretation of recovery, alluded to at the outset. In the last paper, the editors Stastny and Lehmann sum up their position. They believe that a non-medical alternative to psychiatry is possible either within the psychiatric system or outside. Basically, however, they harbor no hope that the psychosocial system will change of its own accord, since it does not support in any substantial manner the organizations of (ex-) users and survivors of psychiatry, the cooperation with other human rights or self-help groups, or promote forms of living with mental problems outside of institutional settings. Psychiatry, they feel, still tends to turn a cold shoulder to the movement of (ex-) users and survivors of psychiatry and its supporters, and to scorn its proposals for reform along with all the important knowledge it has generated. Hopefully this book will help the (ex-) user and survivor movement, not only by introducing a wider public in and out of psychiatry to its very many real accomplishments, its vital importance and its future goals, but also by strengthening the international ties of those directly involved in the movement itself. I can only wish that this book be read by all psychiatrists, especially younger psychiatrists in training, since I am quite certain that they will find much food for thought in its pages. Karl Koehler, M.D.
Alternatives Beyond Psychiatry is written by many authors,
ex-users and survivors of psychiatry, therapists, psychiatrists,
social scientists, lawyers and relatives and they are all in agreement,
as the title suggests, that we need to go beyond psychiatry. Many
of them explain very well that the concept of 'mental illness'
is a stumbling block. Human suffering, interpreted and packaged as a disease, only
makes matters worse for those who suffer while it lucratively
rewards some of those who work in the field, especially the pharmaceutical
companies. Kate Millett writes an amazing account on this point
in the chapter The illusion of mental illness. Hannelore Klafki from Germany could see that her voices had meaning
and Dutch psychiatrist Marius Romme found that when he listened
to his clients, recovery could be achieved by many people labeled
with 'schizophrenia' when the meaning of their voices were understood
and valued. People labeled with 'mental illness' need to be encouraged and
find their strengths. With their emphasis on creativity, inspiration,
alternative healing, modalities, radical egalitarianism and a
commitment to self-determination, they attract many who have been
alienated by other approaches. |
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