reprinted with kind permission of author Judi Chamberlin. Although ON OUR OWN(McGraw-Hill 1978) is out of print, copies are available upon request from the author,
c/o the National Empowerment Center, 20 Ballard Road, Lawrence, MA 01843, for $15 plus shipping ($1 per book). This is the British edition.
Chapter One: A Patient's View of the Mental Health System
Mental health and mental illness are terms that have entered the popular vocabulary. Yet they are terms that few people can define. Lay people and psychiatrists alike tend to call people mentally healthy when they like their behavior and mentally ill when they dislike their behavior. Rebellious teenagers, unhappy housewives, dissatisfied workers, or lonely old people for example, are often diagnosed as mentally ill, which is less a medical, scientific description than it is a judgment that the person so labeled has, in some way, behaved improperly.
We can see this judgmental process at work when we look at the effect that a diagnosis of mental illness has on an individual's life. Unlike physical illnesses, which affect particular parts of a person's body, mental illnesses affect that abstraction known as the mind. Once it has been decided that a person has a sick mind, enormous social consequences ensue. A finding of mental illness, which is often a judicial as well as a medical, determination, frequently results in loss of liberty. People labeled mentally ill are usually presumed to be incapable of exercising their decision-making power in their own best Interest. The compulsory psychiatric treatment of people labeled mentally ill usually involves confinement in a mental hospital, which is widely perceived as an unpleasant and undesirable fate. Mental patients who protest such confinement are seen as being unable to understand their own best interest; and often, once someone has been so diagnosed, even the perception of his or her place of confinement as undesirable or unpleasant is considered a sign of mental illness.
Anything can be called a symptom of mental illness. In ordinary medical usage, the word symptom refers to malfunctiong body parts or systems. One dictionary defines symptom as the "subjective evidence of disease or physical disturbance observed by the patient." Physical symptoms can't always be seen, but they are almost always apparent (and distressing) to the person they affect. In psychiatric usage, it is an individual's behavior that is the symptom, and often the distress is felt less by the person being labeled mentally ill than by those around him. Some people find their own actions so distressing that they go voluntarily to psychiatric clinics or emergency rooms, but frequently prospective patients are brought by family, friends, or the police. Such people don't perceive themselves as ill; their "symptoms" are bothersome to others. Frequent handwashing, staying out late at night, crying, spending a lot of money, expressing an unusual religious preference, wanting a divorce, having trouble in school or on the job, changing one's life-style--all these and many more have been called symptoms of mental illness.
Nor does one's behavior have to be particularly bizarre for one to be considered seriously mentally ill and be committed to a menial hospital. Leonard Roy Frank of San Francisco was thirty years old and living in his own apartment. He was fired from his job, and rather than get another job, he decided to live on his savings and take some time to read and study. He became particularly interested in studying the Bible and in the practice of Orthodox Judaism. He grew a beard, in accordance with Orthodox requirements, and began strict observance of the dietary laws. Several months later, his parents came from New York to visit him and were horrified by his way of life.
I had started going through what I call my changes. I didn't experience fear of the process--I was delighted with this new perspective on who I was and what society was all about. I was reading, studying, and contemplating. When my family visited, they had me institutionalized involuntarily, since I would not cooperate with them by seeking therapy. The outrageous thing was that I was going through this period of self-exploration and growth, and it was interpreted as my having a serious mental disorder.
In 1974, Leonard Frank obtained the medical records of his involuntary incarceration and published them in Madness Network News, a newspaper he helped to start. The records show that the only "symptoms" the psychiatrists were able to find, "symptoms" that they used to justify administering to him against his will fifty insulin shock and thirty-five electric shock treatments, were his vegetarianism, his beard, and his denial that he was mentally ill. During the eight months of his hospitalization, the records show that much medical attention was focused on the question of shaving. After months of refusing to shave voluntarily, Leonard's beard was shaved off while he was unconscious during a shock treatment. Entry after entry in the record is devoted to a solemn recital of the problem of the beard. The record indicates that whenever Leonard was given a mentaI-status examination, he answered all the factual questions correctly; he was, in psychiatric terminology, "well oriented." The doctors' conclusion that he was a paranoid schizophrenic rests on his "bizarre" eating habits, his long hair and beard, and his refusal to admit he was mentally ill was 'lack of insight."
"The Frank Papers" make truly frightening reading. Frank's crime was living his life as he--rather than as his parents and the psychiatrists--chose. After his parents arranged for his commitment and for him to be given shock treatments, they returned to New York. The record contains copies of letters written by the doctors to his parents, reporting on his condition. One letter in particular reveals that the psychiatrists had in mind nothing less than the complete changing of his personality. "He still has all his delusional beliefs regarding his beard, dietary regime and religious observances that he had prior to treatment. We hope that in continuing the treatments we will be able to modify some of these beliefs so that he can make a reasonable adjustment to life." It was considered progress that "he asked for a bowl of clam chowder soup and took some bread and used butter on it." His "delusions"--that he should be a vegetarian, wear a beard, and observe his religion--were enough for a court order of commitment, requested by the doctors on the grounds that he was "dangerous to himself and others under these circumstances". What danger? Whose delusions?
People who are labeled mentally ill become part of a system that deprives them of control over their own life as part of their treatment. Mental hospitals have been called "total institutions" in which even such ordinary decisions as when to eat, go to the toilet, and go to bed are made by others. A natural consequence of being subjected to such a regimen is a feeling of depersonalization. Feelings of depersonalization are frequently considered primary symptoms of mental illness. To complete the circle, psychiatrists usually attribute their patients' feelings of depersonalization to their internal state and not to conditions within mental institutions.
The whole experience of mental hospitalization promotes weakness and dependency. Not only are the lives of patients controlled, but patients are constantly told that such control is for their own good, which they are unable to see because of their mental illness. Patients become unable to trust their own judgment, become indecisive, overly submissive to authority, frightened of the outside world. The antitherapeutic nature of mental hospitalization has long been recognized.
A tremendous gulf exists between patients and staff in mental institutions. Patients are seen as sick, untrustworthy, and needing constant supervision. Staff members are seen as competent, knowledgeable natural leaders. These stereotypes are believed by large numbers of patients and staff members. Communication is difficult across this gulf. Staff members don't believe what patients tell them. Patients don't believe what other patients say. Patients begin to question their own perceptions of situations, including their very accurate perceptions that they are looked down on and spied on by the staff.
Eleven years ago, I spent about five months as a patient in six mental hospitals. The experience totally demoralized me. I had never thought of myself as a particularly strong person, but after hospitalization, I was convinced of my own worthlessness. I had been told that I could not exist outside an institution. I was terrified that people would find out that I was an ex-patient and look down on me as much as I looked down on myself. For years I feared that any stress, any difficulty would lead to my total collapse. But gradually I had to recognize that I was not the fragile shell I believed myself to be. It was a long process. I had to fight the crippling belief In my inferiority, a belief that I had been given by the people I once trusted as healers. It was years before I allowed myself to feel anger at a system that had locked me up, denied me warm and meaningful contact with other human beings, drugged me, and so thoroughly confused me that I thought of this treatment as helpful. Of enormous help in digging through the layers of mystification has been my involvement, for the past six years, In a number of mental patients' liberation groups, in which expatients have come together to validate our own pain and anger.
Out of this anger has come action--working to change commitment laws, to inform patients about their legal rights, to increase Constitutional guarantees to patients, to end the demeaning and harmful psychiatric system and replace it with true asylums, places to which people can retreat to deal with the pain of their existence. We envision a system In which this pain would not be labeled "illness" but would be seen as a natural consequence of a system that puts wealth, property, and power above the basic needs of human beings. These asylums would not be simply more humane mental hospitals, they would be true alternatives to the present mental health system--voluntary, small, responsive to their own communities and to their residents. Alternative facilities already exist in a few places, and more are in the planning stage.
Patient-controlled alternatives can provide services to people without the demoralizing consequences of the authoritarian, hierarchical structure of traditional mental health services. When the emphasis is on people helping one another, the gulf between "patient" and "staff" disappears. Someone can seek help from others without being thought of as sick or helpless. The same person who seeks help can also offer it.
People who have been patients know from their own experience that warmth and support (when they were available) were helpful and that being thought of and treated as incompetent were not. Even when a person is experiencing distress, he or she can still be helpful to others. A person who is experiencing extreme pain may temporarily need to be only a "taker" rather than a giver, but such situations are often relatively short-lived (although being treated badly--as frequently happens in mental institutions--can prolong them). Being able to reach out to another person--even when one is feeling bad oneself--illustrates to the person in distress that he or she is not incompetent and worthless. Taking part in making decisions, even such simple ones as what to have for dinner, shows a person that he or she does have some control over his or her life and gives that person the confidence to participate in more substantial group decision making in such areas as financial policy and staff hiring.
There are immense practical problems involved in trying to set up Patient-controlled alternative facilities and services. Money is difficult to find. Opposition from professionals, who are accustomed to being in charge and to thinking of patients as incompetent, can be enormous. Ex-patients may be uncertain of their own abilities. In later chapters, I describe some of the alternatives that exist and how their organizers dealt with these difficulties.
The label mentally ill implies that a person has a medical problem, one that can be properly treated only by doctors. In mental illness it is the mind that is said to be diseased. The medical model of mental illness--the belief that mental illnesses are directly analogous to physical illnesses--is generally followed by psychiatrists and by the general public. As can be seen in the terms "mental illness," "mental patient," and "mental hospital." But there is another way of looking at mental illness. The opinion that mental illness does not exist has been advanced by, among others, psychiatrist Thomas Szasz, sociologists Thomas Scheff and Erving Goffman, and psychologist Theodore Sarbin. Szasz has written that "although mental illness might have been a useful concept in the nineteenth century, today it is scientifically worthless and socially harmful."' Scheff considers that "mental illness may be more usefully considered to be a social status than a disease, since the symptoms of mental illness are vaguely defined and widely distributed, and the definition of behavior as symptomatic of mental illness is usually dependent upon social rather than medical contingencies." Goffman has pointed out that "society's official view is that inmates of mental hospitals are there primarily because they are suffering from mental illness. However, in the degree that the 'mentally ill' outside hospitals numerically approach or surpass those inside hospitals, one could say that mental patients distinctively suffer not from mental illness, but from contingencies." Sarbin believes that "mental illnesses are not so easily defined as their medical counterparts, physical illness and somatic pathology. . . . Definition of behavior pathology is essentially a cultural matter, dependent on local beliefs and practices. Even within our own culture, widely divergent definitions of mental illness may be found."'
Psychiatrists E. Fuller Torrey and Ronald Leifer hold similar views. According to Torrey, "the very term [mental disease] itself is nonsensical, a semantic mistake. The two words cannot go together except metaphorically; you can no more have a mental 'disease' than you can have a purple idea or a wise space."' Leifer says that "the relationship between psychiatry and medicine is historical and social rather than logical or scientific."'
One does not have to be a mental health professional to enter this debate. What is at issue is whether people with certain types of disturbing behavior are suffering from diseases. Although many psychiatrists claim that their training gives them the expertise to detect symptoms of the various mental illnesses, it is the very existence of mental illness that is in question. Leaving the determination of whether mental illness exists strictly to the psychiatrists is like leaving the determination of the validity of astrology in the hands of professional astrologers. While occasional psychiatrists (or astrologers) may question the very basis of the discipline they practice, such behavior is understandably rare, since people are unlikely to question the underlying premises of their occupations, in which they often have a large financial and emotional stake.
The equation between mental illness and physical illness is not new. Certain kinds of behavior, such as hallucinations, have been labeled illnesses in many cultures and periods of history. What is frequently forgotten is that some other cultures have alternative explanations. A "hallucination" can be an indication that a person has special abilities and should be consulted about major group decisions. Or a "hallucination" may instead be termed a "vision," a religious manifestation (if the person doing the labeling shares the religious beliefs of the visionary). Recently, growing numbers of behaviors are being labeled mental illness--far more than have traditionally been called mad.
The question What is mental illness? leads directly to some of the major philosophical questions with which the human race has grappled throughout history: What is the mind? What is the relationship between the mind and the body? What is the relationship between the brain and the mind? These questions are far too important to be left to psychiatrists, whose medical school training is largely irrelevant to dealing with them. By their training, psychiatrists have already made the assumption that mental illness exists as a counterpart to physical illness.
The law has the Power to compel people to receive treatment for mental illness. This almost never occurs in the case of physical illness, except in rare instances when courts overrule parents who have refused medical treatment for their child. The courts in such instances assume the parens patriae role, acting in lieu of the parents in what the court defines as the child's best interest. When a person of whatever age is ordered by a court to undergo psychiatric treatment, this same parens patriae power comes into effect. This connection between the legal and medical systems puts the mental patient at a disadvantage that is not faced by patients with physical illnesses. Courts usually bow to psychiatric expertise and make the assumption that potential patients are sick and in need of treatment--precisely the question the courts are supposed to determine.
In addition to the parens patriae doctrine, which assumes that a mentally ill Individual is incapable of determining his or her own best interest, an additional doctrine, the police power of the state, is used to justify the involuntary confinement of people labeled mentally ill. This doctrine is based on the assumption that mentally ill people are dangerous and may do harm to themselves or others if they are not locked up. The belief in the dangerousness of the mentally ill is firmly rooted in our culture. It is especially promoted by the mass media, which frequently run stories in which crimes of violence are attributed to a person's mental illness. If the person has been previously hospitalized, that fact is prominently mentioned; if not, frequently a police officer or other authority figure will be quoted to the effect that the accused is "a mental case or a nut." In addition, unsolved crimes are often attributed to "crazies."
In actuality, people who have been hospitalized because of mental illness are not dangerous.The vast majority of former mental patients do not get in trouble with the law. The occasional ex-patients who commit crimes are noticed; law-abiding former patients are not. The police power of the state to commit people to mental institutions rests not only on the shaky premise that mental illness is equivalent to dangerousness but on the equally shaky belief that psychiatrists can accurately predict future violent acts. Law professor Alan M. Dershowitz who conducted a thorough survey of all the published psychiatric literature concerning the prediction of dangerousness, found that less than a dozen papers involved follow-up studies to see whether those the psychiatrists had labeled dangerous actually went on to commit dangerous acts. The studies indicated that the psychiatrists did a rather poor job, greatly overpredicting violence. They labeled violence prone many individuals who were not in fact violent. However, on the basis of psychiatric predictions of future violence, individuals can be subjected to indefinite detention in mental hospitals.
Both the parens patriae power and the police power relate to the stereotyped view of the prospective patient--that he or she is sick, unpredictable, dangerous, unable to care for himself or herself, and unable to judge his or her own best interest. None of these beliefs is scientifically verifiable.
It was in the guise of defining his best interest that the state of Illinois involuntarily committed Robert Friedman to a Chicago mental hospital in February 1975. Friedman's detention made national headlines because he was stopped by the police for panhandling while carrying nearly twenty-five thousand dollars in cash. It was the contention of the state that this showed his poor judgment and inability to care for himself, despite the fact that he had worked for many years (he had been laid off from work a year earlier), lived by himself, and had never been considered in need of care. The psychiatrist who examined him once he was involuntarily confined told the court that Friedman was a "paranoid schizophrenic." Friedman had accumulated his money by years of careful living, but the state, which was presumably protecting him, proved far more reckless with his money than he had been. He was charged eight hundred dollars a month for his care, "care" that so damaged him that seven months later he was unable to live on his own and was placed in a nursing home. In addition, he was required to pay for a lawyer retained by his relatives, who wanted him institutionalized, as well as for his own lawyer, who tried to get him released. On appeal of his case, the state of Illinois filed a confession of error, in which they admitted that there had been no valid reason for his initial commitment. Friedman was by this time suffering from the debilitating effects of confinement and forced medication and was declared legally incompetent. Fourteen months after he was originally found to be mentally ill, Robert Friedman was dead.
Robert Friedman's "symptoms" were his frugality and his panhandling. For these the state deprived him of his liberty, much of his money, his health, and, ultimately, his life.
Psychiatrist Thomas Szasz takes the position that the only proper role for psychiatry in a free society is to work with individual, consenting clients. Institutional psychiatry, in his view, is inherently coercive, since the institutional psychiatrist is the agent not of his patient, who wishes to be free, but of the people who want the patient locked up--sometimes the state, sometimes the patient's family or friends. The patient has no reason to trust the psychiatrist; often the psychiatrist can see this lack of trust only as a sign of the patient's "paranoia." And so the patient gets more of the same treatment he or she has been protesting.
Institutional psychiatric treatment is largely physical in nature. Drugs, the major method of treatment, are known as "major tranquilizers" or "antipsychotic agents." Their main effect is to slow down both thinking and motor activity, and they are responsible for what is widely perceived as a "revolution" in mental hospitals since the early 1950s, when they came into widespread use. Mental institutions are quieter than they used to be, but the slurred speech and stiffly held bodies of the patients reveal the cost of that quiet. The term antipsychotic agent implies that the drug regulates specific malfunctioning parts of the brain, but no proof exists of either the malfunction or the specific corrective power of the drug. The manufacturers of Thorazine, the most widely used major tranquilizer, say that "the precise mechanism whereby the therapeutic effects... are produced is not known.'"
There is another, far less favorable, way to view the widespread use of these drugs, especially when they are forced on patients in mental institutions. The term chemical straitjacket has come into use to describe the effects of tranquilizers. While it may appear far more humane to inject someone with a drug than it is to tie the person up, in actuality they are just two different ways of accomplishing the same thing. And while being tied up can be uncomfortable, it may be preferable to the common side effects of tranquilizers, which include (for Thorazine) lethargy, drowsiness, pseudoParkinsonism, and the possibility of developing an irreversible brain syndrome called tardive dyskinesia (uncontrollable involuntary movements of the mouth, tongue, and jaw, and possibly the extremities). Other major tranquilizers have similar listed side effects.
Tranquilizers are used not only in mental hospitals but in many kinds of institutions where large numbers of people are supervised by underpaid, poorly trained staff members: institutions for the retarded, nursing homes, juvenile detention centers, and prisons. The purpose is clearly institutional management. One study of tranquilizer use in a facility for the retarded concluded that the drugs had a beneficial effect because they made "ward management easier and more pleasant for the attendants, who are now more relaxed." Of course, it was the inmates, not the staff, who ingested the drugs. At the same time, the side effects of the drugs may have made it more difficult for the retarded residents to learn basic self-care skills that might have made it possible for them to live outside the institution.
Mental hospitals are similar to prisons, old-age homes, and state "schools'--all exist to contain various kinds of unwanted people. Mental hospitals add the justification that they are treating illness, but this can be regarded largely as rhetoric.
One of the main functions of the mental hospital, like other "total institutions," is control. The lives of patients are minutely supervised. As psychologist D. L. Rosenhan and his colleagues discovered when they faked the symptoms of mental illness and had themselves admitted to a number of mental hospitals:
Personal privacy is minimal. Patient quarters and possessions can be entered and examined by any staff member, for whatever reason. His personal history and anguish is available to any staff member . , . who chooses to read his folder. ... His personal hygiene and waste evacuation are often monitored. The water closets may have no doors. ... The pseudopatients had the sense that they were invisible, or at least unworthy of account. Upon being admitted, I and other pseudopatients took the initial physical examination in a semipublic room, where staff members went about their own business as if we were not there.
All the volunteers in the study experienced depersonalization, not because they were mentally ill but because "patient contact is not a significant priority in the traditional psychiatric hospital."
What most psychiatrists call mental illness, Thomas Szasz has called "problems in living." People who seek help with their problems in living find that help is frequently unavailable in cold, impersonal mental hospitals. People would find their needs far better served by small, voluntary community facilities where all participated in decision making and none were seen as less than human. But help must be wanted. Robert Friedman, for example, or Leonard Roy Frank needed simply the right to be left alone. "My only problem in living," says Leonard Frank, "was that other people wouldn't leave me alone."
When people do have problems in living, they can help one another. Psychiatrists have no monopoly on knowledge about loneliness, alienation, anger, or any other difficulties of living. In fact, psychiatrists (who are often middle or upper class) may never have faced the kinds of problems their poorer patients face daily. The mental hospital, where understanding human contact is at a premium and where psychotherapy (whatever its value may be) is almost unheard of, is hardly the place where people can learn useful new ways of dealing with life. Instead, knowing that there must be a better way, people have banded together to set up all kinds of alternative institutions. Hot lines, crisis centers, and counseling centers of all sorts were set up in many areas during the 1960s. Many have folded, but others are going into their second decade of existence, and new ones are springing up all the time. Psychiatric outpatient facilities such as halfway houses and social clubs are also increasing rapidly.
Alternatives of all sorts exist, but here it becomes important to define what is meant by an alternative. Some are merely mini-institutions in the community, where psychiatrists supervise staffs of nurses and paraprofessionals, where residents' lives are strictly controlled, and where drugs are compulsory. Often a veneer of democracy is provided, in which the residents vote on what to have for dinner or what movie to see, but real decisions, such as who gets to live in the facility or what the rules are, are firmly in professional hands. Other alternatives are more truly democratic, although in almost all, the staff/patient (or staff/resident or staff/client) dichotomy still exists. What I define as a true alternative is one in which all basic decision-making power is in the hands of those the facility exists to serve. Such places are rare, but where they do exist, they show clearly how well people can help one another in environments that have been set up to maximize the strengths and abilities of each participant.
Let me make clear what I do not see as models for the future. The typical halfway house is run along the same authoritarian, hierarchical lines as the typical mental hospital, although on a far smaller scale. Dr. Richard Budson, a psychiatrist at Harvard Medical School, describes the movement toward halfway houses as "a truly collaborative program between professionals, paraprofessionals, the community and its service agencies"--the prospective residents play no part at all. The authoritative survey The Halfway House Movement states that "all facilities defined as halfway houses [in the survey] maintain something of a professional orientation" and notes that "whether the residents themselves would paint similar pictures [to that provided by the administrators and directors] is, of course, an open question." Since the residents are still faceless and voiceless, this "alternative" is still far too close to the old model.
The "therapeutic community" was introduced by psychiatrist Maxwell Jones as an improvement over the traditional organization of the mental hospital ward. So-called therapeutic communities have become a fad in progressive mental hospitals--recognizable by the innumerable ward meetings, which take innumerable votes on every minor decision of ward life while the staff continues to make major decisions behind closed doors. Jones has written that "in a therapeutic community the whole of a patient's time spent in hospital is thought of as treatment." The orientation is very much within the medical model--the patient is sick, the staff is well, and the goal of hospitalization is to cure the patient. The method of the therapeutic community is described as democratic, but only if one accepts the strange definition of democracy of psychiatrist Philip Margolis, who describes it as a situation in which "one person was responsible but he permitted the group decision to prevail with the understanding that he could overrule it if he wished." Margolis, describing the therapeutic community he ran at the University of Chicago Hospital, says of it:
If not a "true" democracy, the ward was truly an egalitarian society, with equality of opportunity. (Almost) all members of the community were subject to the same rules and working conditions and equal rights and privileges, taking into account their particular role in the community. Staff was staff, and patients were patients; there was still a staff hierarchy; and some patients were sicker than others. But these conditions and circumstances were understandable and were made explicit and part of the "game" of which there were definite "rules."
The kinds of rules that Margolis speaks of exist in many mental hospital therapeutic communities. Typical is an eight page list of rules distributed by the Adolescent Unit of Haverford (Pa.) State Hospital to its patients.31 Incoming patients are assigned to Phase I; they are allowed off the unit only when escorted by a staff member and may receive phone calls or visits from their family at the discretion of the staff. In order to "graduate" to Phase II, patients must satisfy the staff that "you are actively working on your problems and participating in the therapies provided." Many adolescents are hospitalized because they do not meet parental expectations; "actively working on your problems" clearly means modifying one's behavior in the direction of those expectations. Adolescent rebellion becomes mental illness.
The phase system continues with Phases III to V, which involve the patient in community votes, that is, patients in the higher phases vote on each patient's phase status.
The community will vote on granting the change you requested. A majority vote decides. However, because the staff bears final responsibility, it must reserve the right to overrule a community decision when necessary.
In Phases IV and V, patients become "buddies," assigned to accompany lower-phase patients off the ward. Buddies are responsible for reporting to staff any rule violations by the person they are paired with.
It is very difficult to maintain one's integrity under the therapeutic community system. Patients are required--in plain English--to rat on one another. Resisting the system can result in punishment. For example, "if areas [of the ward] are found disorderly, the entire community [excluding, obviously, the staff] shall be held accountable and restrictions given." Patients are required to enforce the standards and expectations of the staff. But is conformity truly a measure of mental health?
People who write therapeutic community rules seem to think so. Restrictions (staying in one's room from dinner to bedtime) are issued for such offenses as "being in cars on the grounds . . . excessive use of profanity ... and inappropriate behavior [a particularly open-ended rule]." The stated aim is "to help you learn to get what you want in life by gaining self control over what you do." Under this system, a patient has little choice but to decide (or appear to decide) to do what is expected. The mystification inherent in the phrase "what you wish to do" is obvious within such a coercive system.
Recreational and service facilities for ex-patients are also typically run along authoritarian and undemocratic lines, especially when it comes to major decisions. We will take a closer look at Fountain House and Center Club, two wellknown examples, in chapter 4.
Patient-run and patient-controlled alternatives are quite different. Rather than a hierarchical structure in which some participants are clearly in charge of others, true alternatives feature a cooperative and democratic structure. Although there may be divisions of function, they are fluid, and one who takes the helping role at one point may be the one who receives help at another. Most important, they are places where no one no matter how poorly functioning, is looked down on as hopeless or as less than human.
Ideally. a network of community facilities for people in acute crisis and for people with long-term difficulties would eliminate mental hospitals entirely. Facilities would differ, depending on the neighborhood and the kinds of clients they served, but all would be run democratically, with basic decision-making power in the hands of clients. People would not be considered sick or well but would be seen as individuals coping with their lives to the best of their abilities. Unique and special needs would be recognized. Third-world people, for example, could run facilities in which all participants understood the experience of being minority group members and useful coping mechanisms would not be dismissed as pathological. Healthy and vigorous elderly people could act as resource people for less able older people. Homosexuals could provide role models for other, troubled gay people. Rather than becoming passive recipients of institutional "care," troubled people would be helped to see the strong and positive aspects of themselves as they, in turn, help others.
The definition of need would come from the client. People behaving in ways that other people found troublesome but that they themselves found satisfactory could not be forced to partake of any services, no matter how humane, against their will. The social control functions of the -current psychiatric system cannot be carried over into the alternative model, or it loses its alternative quality. The alternative system would leave Robert Friedman or Leonard Roy Frank quite properly alone.
It will be objected that this will leave untreated many people who require "treatment." But two hundred years of institutional psychiatry have shown that mental hospitals cannot help the unwilling. Incarceration is not treatment.