ALTERNATIVES BEYOND PSYCHIATRY: Peter Stastny / Peter Lehmann (Eds.). Soft cover, 432 pages, 3 figures, 14,8 x 21 cm, British ISBN 978-0-9545428-1-8, American ISBN 978-0-9788399-1-8. Berlin · Eugene, OR (USA) · Shrewsbury (UK): Peter Lehmann Publishing 2007.

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 Skane, 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.

Professor Emeritus of Psychiatry, Bonn