AACP Newsletter, Volume 12, Number 4, Autumn 1998
Editor's Column
Activism and Autonomy:
Consumers of Psychiatric and Addiction Services
Mental illness has been addressed in a variety of ways in different cultures as civilization has developed. It has been seen as both a spiritual disturbance and a medical problem prior to the modern era and attempts at treatment have included a wide array of ideas, many of which would seem absurd today. In the United States the asylum became the predominant method for dealing with mental disturbances, effectively removing those affected by these disorders from general society. The oversight of these institutions and the individuals in them was provided primarily by the medical profession throughout much of their history in this country. Psychiatry grew from this group of mental hospital superintendents and it has continued to have considerable influence over the treatment provided to persons with mental illness. Much has changed, of course, in the past thirty years, with only a small percentage of the population affected by mental illness now being housed in mental institutions.
As deinstitutionalization became a reality, significant issues arose regrading the nature of mental illness and the rights of individuals affected by it. Persons with mental illness were often subjected to coerced treatment and in many cases these treatments were perceived to be oppressive, intrusive, and humiliating. They were at the mercy of their "protectors" and had little power or voice in the type of treatment they received. Physicians and other mental health professionals were often perceived to be indifferent at best and sadistic and self-serving in other instances. The mental health consumer came to see many of the treatments they were forced or coerced to accept as expedient methods of control rather than legitimate attempts to improve their condition. They felt diminished and devalued as human beings by a paternalistic system based on a medical model of disease which deligitimized alternative realities.
As with mental illness, there have been a variety of perspectives on substance using behaviors throughout history. Excessive substance use was generally viewed differently than its mental illness counterpart, however. Although it has often been seen as a spiritual or moral weakness, outside of its affects on the user's health or its ability to cause physiologic dependence, it has not often been conceived to be a medical problem. Although this point has been debated by society and the medical profession for some time, and despite compelling arguments which would indicate its similarity to other diseases, our current social policy demonstrates that our predominant perspective has been the rejection of this position. Until recently, it has been largely rejected by the medical profession as well. Although physicians have played a role in the treatment of detoxification throughout history, they had little to offer the addict beyond this. Unlike the person affected by mental illness, unusual behavior by an intoxicated individual was not generally suppressed by segregation or other types of isolation unless that individual broke the law. It was only in those instances that addicts were deprived of their liberty and removed from society. Even though several states have passed civil commitment laws for persons with uncontrolled and potentially dangerous use of substances, these laws have been seldom used.
The addiction treatment paradigm developed independently from the medical establishment and the medical model, and grew predominantly from the Alcoholics Anonymous movement which began more than 60 years ago and proposed a 12-step, mutual support approach to recovery. The notion that an individual affected by a substance use disorder must be motivated to change before treatment could be effective has been widely accepted and, until more recent scrutiny of this assumption, addicts were seldom coerced to take part in unwanted treatment. Anonymity has remained an important aspect of this movement, and even as treatment methodology has become more complex and diverse, concepts of acceptance, personal motivation for change, and responsibility have remained as the cornerstones of recovery. The recovering addict has assumed a prominent role as mentor and often as therapist in this treatment culture. By contrast, the physician has had a relatively peripheral role in the provision of direct services or in exerting influence over treatment design.
As a result of these traditions, consumers of mental health and addiction services have been distinct in their approach to advocacy and activism within society. Mental health consumers (or survivors) have been united by their anger as well as their common experiences and have channeled their energy toward organizing themselves to achieve political potency and toward the prevention of the recurrence of past abuses. Their anger has often been directed toward psychiatrists and the systems responsible for their care. These efforts have resulted in greater participation in individual treatment planning and greater representation in the development of services within systems of care.
By contrast, addicts in recovery have had little visibility on the public stage and have been relatively ineffective agents for change in the organization of services or of the punitive approaches commonly applied to substance use problems. The tradition of anonymity has contributed to this aversion to activism, but the uncoerced and peer supported treatment experiences they have had leave them with little reason for bitterness toward the system. The emphasis on their recovery has been one of individual responsibility and a focus on acceptance of external realities. Recovery encourages one to moderate rebellion against external circumstances until control of internal experience, interpersonal interaction, and personal behavior have been achieved.
The principles of recovery have recently become more recognized by mental health consumers and they have provided a useful framework for those seeking greater empowerment and autonomy. The addiction recovery community has remained an impotent force in advocating for their fellow suffers, and they have sometimes looked with envy upon the accomplishments of mental health consumers' activism.
The moral of this story is, of course, that we all have much to learn from other cultures and traditions, and if our minds are open we may find much to compliment our own perspectives or approaches. As we move toward greater integration of the services that are provided for persons with mental health and/or addiction problems, we will be wise to keep this idea on our desktop. Whether we are consumers or providers, we will need to find the best aspects of every approach, and set aside preconceived notions of how things ought to be. We know that sometimes something good (activism) arises from adversity (coercion and mistreatment) and that negative consequences (isolation and impotence) may arise from seemingly healthy circumstances (recovery and autonomy). If we could set aside politics and self-interest, if we could think outside the box, think how much we might accomplish.
Wesley Sowers, MD
Editor
Back to Autumn 1998 Table of Contents