Removable partial denture

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https://en.wikipedia.org/wiki/Removable_partial_denture 

 

Removable partial denture
MeSH	D003832

A removable partial denture (RPD) is a denture for a partially edentulous patient who desires to have replacement teeth for functional or aesthetic reasons and who cannot have a bridge (a fixed partial denture) any reason, such as a lack of required teeth to serve as support for a bridge (i.e. distal abutments) or financial limitations.

This type of prosthesis is referred to as a removable partial denture because patients can remove and reinsert it when required without professional help. Conversely, a "fixed" prosthesis can and should be removed only by a dental professional.

Usage

RPD may be used when there is a lack of required teeth to serve as support for a bridge (i.e. distal abutments) or financial limitations. A single-tooth RPD known as a "flipper tooth" may be used temporarily after a tooth is extracted, during the several months it takes to complete the placement of a dental implant and crown.

Classification

The images above show the same Removable Partial Denture (RPD) for a patient whose mandible is partially edentulous. Their mouth is Kennedy classification II RPD as evidenced by the unilateral row of teeth on the right side of the denture. An embrasure clasp is viewable on the device's left half, as well as two cingulum rests for the two canine's on the mandible. The major connector is either a lingual bar or a sublingual bar.

The patient's oral condition is categorized based on the remaining dentition in a classification first proposed by Dr. Edward Kennedy in 1925. His classification consisted of four general outlines for partially edentulous arches that can present within a patient, which then could be treated with an RPD. When there is an edentulous space that is outside of the four classifications, it is termed a modification space. The use of this classification allows for easier communication between dental professionals, allows for easily visualization of the arch, and distinguishes a tooth-borne or tissue-supported RPD.

• Class I (bilateral free ended partially edentulous)
• Class II (unilateral free ended partially edentulous)
• Class III (unilateral bounded partially edentulous)
• Class IV (bilateral bounded anterior partially edentulous)

Kennedy Class I RPDs are fabricated for people who are missing some or all of their posterior teeth on both sides (left and right) in a single arch (either mandibular or maxillary), and there are no teeth posterior to the edentulous area. In other words, Class I RPDs clasp onto teeth that are more towards the front of the mouth, while replacing the missing posterior teeth on both sides with false denture teeth. The denture teeth are composed of either plastic or porcelain.

Class II RPDs are fabricated for people who are missing some or all of their posterior teeth on one side (left or right) in a single arch, and there are no teeth behind the edentulous area. Thus, Class II RPDs clasp onto teeth that are more towards the front of the mouth, as well as on teeth that are more towards the back of the mouth of the side on which teeth are not missing, while replacing the missing more-back-of-the-mouth teeth on one side with false denture teeth.

Class III RPDs are fabricated for people who are missing some teeth in such a way that the edentulous area has teeth remaining both posterior and anterior to it. Unlike Class I and Class II RPDs which are both tooth-and-tissue-borne (meaning they both clasp onto teeth, as well as rest on the posterior edentulous area for support), Class III RPDs are strictly tooth-borne, which means they only clasp onto teeth and do not need to rest on the tissue for added support. This makes Class III RPDs exceedingly more secure as per the three rules of removable prostheses that will be mentioned later, namely: support, stability and retention.

However, if the edentulous area described in the previous paragraph crosses the anterior midline (that is, at least both central incisors are missing), the RPD is classified as a Class IV RPD. By definition, a Kennedy Class IV RPD design will possess only one edentulous area.

Class I, II and III RPDs that have multiple edentulous areas in which replacement teeth are being placed are further classified with modification states that were defined by Oliver C. Applegate. Kennedy classification is governed by the most posterior edentulous area that is being restored. Thus if, for example, a maxillary arch is missing teeth #1, 3, 7-10 and 16, the RPD would be Kennedy Class III mod 1. It would not be Class I, because missing third molars are generally not restored in an RPD (although if they were, the classification would indeed be Class I), and it would not be Class IV, because modification spaces are not allowed for Kennedy Class IV.

The results of a study conducted in Saudi Arabia, showed that the occurrence of Kennedy Class III partial edentulism was 67.2% in the maxillary arch and 64.1% in the mandibular arch. Followed by Class II in both maxillary and mandibular arch with an average of 16.3% in maxillary arch and 14.8% in the mandibular arch. Based on these results, class III has the highest prevalence in younger group of patient (31– 40 years). Class I and class II have the highest incidence among older group of Patients (41–50 years).

Design

Prior to designing partial dentures a complete examination is undertaken to assess the condition of remaining teeth. This may involve radiographs, sensibility testing or other assessments. From this examination and assessment of occlusion (occlusal plane, drifting, tilting of teeth and surveyed articulated casts) the designing of partial dentures can begin. Information from previous dentures can be very useful in deciding which features to keep the same and which features of the design to change – in the hope of making an improvement.

Stages of partial denture design

A systematic design process should be followed:

• The teeth to be replaced must be decided.
• The soft tissue to be replaced (flange) is then drawn.
• The major connector is selected from a list of options (the options available will depend on the above assessment).
• Retentive features of the denture must be decided – these may include clasps, guide planes and indirect retention (often important in dentures involving Kennedy Class 1 and Class 2 saddles).
• Supportive features are then decided – these prevent the denture sinking into the soft tissue; often the natural teeth can take some of the loading (rest seats and connector coverage).

However, this is not always possible. Support may thus be tooth-borne, mucosal borne or a combination of tooth and mucosal borne.

• The denture should where possible have features that withstand horizontal movement (bracing) and the clasps should have appropriate reciprocation.
• The denture base material (usually acrylic or cobalt-chromium) and materials of the various components must be selected.
• The hygiene of the prosthesis must be appropriate trying where possible to minimise the soft tissues coverage.

The design should be reviewed and simplified removing unnecessary components.

Once the partial denture has been designed, the shade and mould of the replacement teeth can be selected. Within the design process (and prior to the master impression stage of denture construction), modifications may be suggested to teeth. This may be undertaken to create occlusal space for rest seats or to create undercuts for the placement of clasps (such as addition of composite resin) or to create guide planes for easier insertion and removal of the denture.

Components

Removable partial denture made from flexible nylon resin

Rather than lying entirely on the edentulous ridge like complete dentures, removable partial dentures possess clasps of cobalt-chrome or titanium metal or plastic that "clip" onto the remaining teeth, making the RPD more stable and retentive.

The parts of an RPD can be listed as follows (and are exemplified by the picture above):

• Major connector (The thick metal "U" in the RPD image above is a lingual bar, a type of major connector)
  • Anterior-posterior palatal strap
  • Single palatal strap
  • U-shaped palatal connector (Horseshoe)
  • Lingual bar
  • Lingual plate
• Minor connector (See the small struts protruding from the lingual bar at roughly 90 degree angles.)
• Direct retainer (Examples are in the upper left of upper photo and lower right of lower photo; the clasp arms act to hug the teeth and keep the RPD in place. The metal clasp and rest immediately adjacent to the denture teeth is also a direct retainer.)
• Indirect retainer (An example is the little metal piece coming off the "U" at a 90 degree angle near the top of the upper photo, which is a cingulum rest on a canine.)
  • Physical retainer (This is a mesh of metal that allows the pink base material to connect to the metal framework of the RPD. Some consider physical retainers their own component (making a total of seven), while others consider them within the indirect retainer category (thus making a total of six components.)
• Base (the pink material, mimicking gingiva)
• Teeth (plastic or porcelain formed in the shape of teeth)

Major connectors for upper teeth

Acrylic denture plate

 

Palatal bar

 

U shaped or "horse shoe" denture

 

Spoon denture

There are many options for major connectors for removable upper partial dentures. The type of connector used will vary depending on the specific circumstances and the results of a comprehensive examination and discussion with the patient. Commonly used major connectors are outlined in the table below along with details of factors affecting the choice of using them.

Plate

Advantages of plates are that they are useful when several teeth are missing or there are multiple saddle. They also provide more retention, stability and support due to larger palatal coverage. Plates are useful when there are long distal extensions.

Disadvantages of plates are that they overs a lot of patients mouth so sometimes not well tolerated and also may affect phonetics. Plates can be problematic if there is a torus palatinus.

Palatal bar (Strap/Anterior-Posterior)

Advantages of these are their rigidity and minimal soft tissue coverage yet still having good resistance to deformation. A-P strap useful for Kennedy class I and II or if there is a torus. A-P strap gives greater distribution of stresses.

Disadvantages of these are that there is not much support due to less palatal coverage and also that is it bulky and so disliked by some patients.

U-shaped palatal bar (horseshoe connector)

Advantages of these are that they are useful in cases where we do not want to cover much of the palate e.g. if patient has a strong gag reflex, a large palatal torus or Kennedy class III.

Disadvantages of these are that they are flexible due to distal extensions which can have adverse effects on force transmission to abutment teeth. They can traumatic to the residual ridge.

Spoon denture

Advantages of these are that they are useful in small anterior saddles and are cheap to make.

Disadvantages of these are that they have large palatal coverage for a small saddle.

Palatal Strap/Bar (Single/Anterior, mid or Posterior)

Advantages of these are that single strap is useful for Kennedy class III and IV cases.

Disadvantage of these are that single strap requires careful placement if there is a torus palatinus. They are generally inappropriate for Kennedy Class 1 or 2.

Major connectors for lower teeth

Lingual bar

 

Sublingual bar

 

Lingual plate

 

Buccal bar (Note the lingual tilting of the teeth meaning a buccal bar is required for a suitable path of insertion/removal.)

A major connector is the part of a partial denture that links components on one side of the arch with those on the other. It must be strong and rigid enough to provide a suitable skeleton to the prosthesis and located so as not to damage the gingival or movable tissues. Five types of major connectors are listed below:

Lingual bar

A lingual bar has a pear-shaped cross section tapering towards the gingival boundary. It should be positioned high enough so as to not irritate the lower movable tissue but low enough to allow for a substantial quantity of material to be used to ensure stiffness. At least 7mm of space is usually required. It sits on the soft tissue posteriorly to the dentition. Along with the lingual plate it is the most commonly used type of connector in the lower arch.

A lingual bar is more hygienic than a lingual plate but is difficult to add to if teeth are later extracted and require to be added to the denture.

Sublingual bar

A sublingual bar is similar to a lingual bar but is located on the floor of the mouth posteriorly and inferiorly to its usual location. They are used when the superior border of a lingual bar would be positioned too closely to the gingival border. They are contraindicated in patients with a high lingual frenum and in situations where they may interfere with tongue movements.

Lingual Plate

A lingual plate is a thin plate contoured to the lingual surfaces of the lower anterior teeth. A lingual plate is useful when there is insufficient space for a lingual bar which would result in irritation of the gingival boundary.

If the teeth are spaced out and the patient does not wish for visible metal to be seen then an interrupted lingual plate may be used where the material is cut away where it would be visible anteriorly.

A disadvantage of a lingual plate is that it covers a lot of gingival margins and is less hygienic than a lingual bar. It should be used with caution in those patients with a high caries rate. A major advantage is that is easier to add teeth to a denture with a lingual plate than a lingual bar connector. In addition, it is useful in providing some additional support for mobile lower anterior teeth.

Buccal bar

In rare cases where the inclination of the remaining anterior teeth is problematic and the use of a lingual connector inappropriate, a buccal bar can be considered.

Continuous clasp

Continuous Clasp in combination with a lingual bar

A continuous clasp is sometimes used in addition to a lingual bar and rarely as a sole major connector. It involves a bar of material placed along the cingulum of the anterior dentition.

The continuous clasp has the added advantage of providing indirect retention when used in addition to a lingual bar. It may be used when a lingual plate is compromising aesthetics.

Clasp design

Direct retainers may come in various designs:

• Cast circumferential clasp (suprabulge)
  • Akers'
  • Half and half
  • Back-action
  • Ring clasp
• Wrought wire clasp
• Roach clasp (infrabulge)
  • I-bar
  • T-bar
  • Y-bar
  • 7-bar

Both cast circumferential and wrought wire clasps are supra bulge clasps, in that they engage an undercut on the tooth by originating coronal to the height of contour, while Roach clasps are infrabulge clasps and engage undercuts by approaching from the gingival.

In addition there are a couple of specific theories which include the clasp design:

• RPI: mesial rest, distolingual guide plate, I-bar
  • The RPI design was made for clasping a bilateral free end extension. These clasps are unique because they have to take into account extra torque force due to being tissue borne (and not tooth borne) at the posterior.
  • Described by Kratochvil in 1963 and modified by Krol in 1973
    • Kratochvil designed the abutment tooth with a long rest (from the mesial marginal ridge to the distal pit), long guide plane, and a regular I-bar clasp.
    • Krol modified this design with a short occlusal rest, short guide plane (touching only from occlusal to middle third), and a mesial-shifted I-bar. The theory behind Krol's decision was to allow for movement of the partial denture without placing too much torque on the abutment tooth.
  • An illustration of the RPI design function
• RPA: mesial rest, distolingual guide plate, Akers' clasp-style retentive arm
• RPC: mesial rest, distolingual guide plate, other type of cast circumferential clasp
  • So named in response to the RPI Philosophy introduced by Kratochvil and Kroll

Indirect retention

Indirect retention is required to prevent displacement of saddles, such as free-end saddles or anterior saddle which is curved outside a straight line between the abutment teeth. Such indirect retention can only be achieved where both claps and rests work together to form lever system (Class III lever system) to retain the free part of denture.

Sanism

From Wikipedia, the free encyclopedia

https://en.wikipedia.org/wiki/Autism_rights_movement

Mentalism or sanism describes discrimination and oppression against a mental trait or condition a person has, or is judged to have. This discrimination may or may not be characterized in terms of mental disorder or cognitive impairment. The discrimination is based on numerous factors such as stereotypes about neurodivergence, for example autism, learning disorders, ADHD, bipolar, schizophrenia, and personality disorders, specific behavioral phenomena such as stuttering and tics, or intellectual disability.

Like other forms of discrimination such as sexism and racism, mentalism involves multiple intersecting forms of oppression, complex social inequalities and imbalances of power. It can result in covert discrimination by multiple, small insults and indignities. It is characterized by judgments of another person's perceived mental health status. These judgments are followed by actions such as blatant, overt discrimination which may include refusal of service, or the denial of human rights. Mentalism impacts how individuals are treated by the general public, by mental health professionals, and by institutions, including the legal system. The negative attitudes involved may also be internalized.

The terms mentalism, from "mental", and sanism, from "sane", have become established in some contexts, though concepts such as social stigma, and in some cases ableism, may be used in similar but not identical ways.

While mentalism and sanism are used interchangeably, sanism is becoming predominant in certain circles, such as academics, those who identify as mad and mad advocates and in a socio-political context where sanism is gaining ground as a movement. The movement of sanism is an act of resistance among those who identify as mad, consumer survivors, and mental health advocates. In academia evidence of this movement can be found in the number of recent publications about sanism and social work practice.

Mentalism tends to be referred as mental disability, distinguishing itself from ableism, which refers to physical disability.

Origin of terms

"Sanism" was coined by Morton Birnbaum.

The term "sanism" was coined by Morton Birnbaum during his work representing Edward Stephens, a mental health patient, in a legal case in the 1960s. Birnbaum was a physician, lawyer and mental health advocate who helped establish a constitutional right to treatment for psychiatric patients along with safeguards against involuntary commitment. Since first noticing the term in 1980, New York legal professor Michael L. Perlin subsequently continued its use.

"Mentalism" was coined by Judi Chamberlin.

In 1975 Judi Chamberlain coined the term mentalism in a book chapter of Women Look at Psychiatry. The term became more widely known when she used it in 1978 in her book On Our Own: Patient Controlled Alternatives to the Mental Health System, which for some time became the standard text of the psychiatric survivor movement in the US. People began to recognize a pattern in how they were treated, a set of assumptions which most people seemed to hold about mental (ex)patients regardless of whether they applied to any particular individual at any particular time – that they were incompetent, unable to do things for themselves, constantly in need of supervision and assistance, unpredictable, likely to be violent or irrational etc. It was realized that not only did the general public express mentalist ideas, so did ex-patients, a form of internalized oppression.

As of 1998 these terms have been adopted by some consumers/survivors in the UK and the USA, but had not gained general currency. This left a conceptual gap filled in part by the concept of 'stigma', but this has been criticized for focusing less on institutionalized discrimination with multiple causes, but on whether people perceive mental health issues as shameful or worse than they are. Despite its use, a body of literature demonstrated widespread discrimination across many spheres of life, including employment, parental rights, housing, immigration, insurance, health care and access to justice. However, the use of new "isms" has also been questioned on the grounds that they can be perceived as divisive, out of date, or a form of undue political correctness. The same criticisms, in this view, may not apply so much to broader and more accepted terms like 'discrimination' or 'social exclusion'.

There is also the umbrella term ableism, referring to discrimination against those who are (perceived as) disabled. In terms of the brain, there is the movement for the recognition of neurodiversity. The term psychophobia (from psyche and phobia) has occasionally been used with a similar meaning.

Social division

According to Coni Kalinowski (a psychiatrist at the University of Nevada and Director of Mojave Community Services) and Pat Risser (a mental health consultant and self-described former recipient of mental health services), mentalism at one extreme can lead to a categorical dividing of people into an empowered group assumed to be normal, healthy, reliable, and capable, and a powerless group assumed to be sick, disabled, crazy, unpredictable, and violent. This divide can justify inconsiderate treatment of the latter group and expectations of poorer standards of living for them, for which they may be expected to express gratitude. Further discrimination may involve labeling some as "high functioning" and some as "low-functioning"; while this may enable the targeting of resources, in both categories human behaviors are recast in pathological terms.

The discrimination can be so fundamental and unquestioned that it can stop people truly empathizing (although they may think they are) or genuinely seeing the other point of view with respect. Some mental conditions can impair awareness and understanding in certain ways at certain times, but mentalist assumptions may lead others to erroneously believe that they necessarily understand the person's situation and needs better than they do themselves.

Reportedly even within the disability rights movement internationally, "there is a lot of sanism", and "disability organisations don't always 'get' mental health and don't want to be seen as mentally defective." Conversely, those coming from the mental health side may not view such conditions as disabilities in the same way.

Some national government-funded charities view the issue as primarily a matter of stigmatizing attitudes within the general public, perhaps due to people not having enough contact with those (diagnosed with) mental illness, and one head of a schizophrenia charity has compared mentalism to the way racism may be more prevalent when people don't spend time together throughout life. A psychologist who runs The Living Museum facilitating current or former psychiatric patients to exhibit artwork, has referred to the attitude of the general public as psychophobia.

Clinical terminology

Mentalism may be codified in clinical terminology in subtle ways, including in the basic diagnostic categories used by psychiatry (as in the DSM or ICD). There is some ongoing debate as to which terms and criteria may communicate contempt or inferiority, rather than facilitate real understanding of people and their issues.

Some oppose the entire process as labeling and some have responded to justifications for it – for example that it is necessary for clinical or administrative purposes – as the way a person may justify the use of ethnic slurs because they intend no harm. Others argue that most aspects could easily be expressed in a more accurate and less offensive manner.

David Oaks, 2009

Some clinical terms may be used far beyond the usual narrowly defined meanings, in a way that can obscure the regular human and social context of people's experiences. For example, having a bad time may be assumed to be decompensation; incarceration or solitary confinement may be described as treatment regardless of benefit to the person; regular activities like listening to music, engaging in exercise or sporting activities, or being in a particular physical or social environment (milieu), may be referred to as therapy; all sorts of responses and behaviors may be assumed to be symptoms; core adverse effects of drugs may be termed side effects.

The former director of a US-based psychiatric survivors organization focused on rights and freedoms, David Oaks, has advocated the taking back of words like "mad", "lunatic", "crazy" or "bonkers". While acknowledging that some choose not to use such words in any sense, he questions whether medical terms like "mentally ill", "psychotic" or "clinically depressed" really are more helpful or indicative of seriousness than possible alternatives. Oaks says that for decades he has been exploring the depths of sanism and has not yet found an end, and suggests it may be the most pernicious 'ism' because people tend to define themselves by their rationality and their core feelings. One possible response is to critique conceptions of normality and the problems associated with normative functioning around the world, although in some ways that could also potentially constitute a form of mentalism. After his 2012 accident breaking his neck and subsequent retirement, Oaks refers to himself as "PsychoQuad" on his personal blog.

British writer Clare Allen argues that even reclaimed slang terms such as "mad" are just not accurate. In addition, she sees the commonplace mis-use of concepts relating to mental health problems – including for example jokes about people hearing voices as if that automatically undermines their credibility – as equivalent to racist or sexist phrases that would be considered obviously discriminatory. She characterises such usage as indicating an underlying psychophobia and contempt.

Blame

Graffiti on a mental health advocacy service

Interpretations of behaviors, and applications of treatments, may be done in an judgmental way because of an underlying mentalism, according to critics of psychiatry. If a recipient of mental health services disagrees with treatment or diagnosis, or does not change, they may be labeled as non-compliant, uncooperative, or treatment-resistant. This is despite the fact that the issue may be healthcare provider's inadequate understanding of the person or their problems, adverse medication effects, a poor match between the treatment and the person, stigma associated with the treatment, difficulty with access, cultural unacceptability, or many other issues.

Mentalism may lead people to assume that someone is not aware of what they are doing and that there is no point trying to communicate with them, despite the fact that they may well have a level of awareness and desire to connect even if they are acting in a seemingly irrational or self-harming way. In addition, mental health professionals and others may tend to equate subduing a person with treatment; a quiet client who causes no community disturbance may be deemed improved no matter how miserable or incapacitated that person may feel as a result.

Clinicians may blame clients for not being sufficiently motivated to work on treatment goals or recovery, and as acting out when things are not agreed with or are found upsetting. But critics say that in the majority of cases this is actually due to the client having been treated in a disrespectful, judgmental, or dismissive manner. Nevertheless, such behavior may be justified by characterizing the client as demanding, angry or needing limits. To overcome this, it has been suggested that power-sharing should be cultivated and that when respectful communication breaks down, the first thing that needs to be asked is whether mentalist prejudices have been expressed.

Neglect

Mentalism has been linked to negligence in monitoring for adverse effects of medications (or other interventions), or to viewing such effects as more acceptable than they would be for others. This has been compared to instances of maltreatment based on racism. Mentalism has also been linked to neglect in failing to check for, or fully respect, people's past experiences of abuse or other trauma.

T-shirt intended to show the possibility and individuality of recovery

Treatments that do not support choice and self-determination may cause people to re-experience the helplessness, pain, despair, and rage that accompanied the trauma, and yet attempts to cope with this may be labeled as acting out, manipulation, or attention-seeking.

In addition, mentalism can lead to "poor" or "guarded" predictions of the future for a person, which could be an overly pessimistic view skewed by a narrow clinical experience. It could also be made impervious to contrary evidence because those who succeed can be discounted as having been misdiagnosed or as not having a genuine form of a disorder — the No true Scotsman fallacy. While some mental health problems can involve very substantial disability and can be very difficult to overcome in society, predictions based on prejudice and stereotypes can be self-fulfilling because individuals pick up on a message that they have no real hope, and realistic hope is said to be a key foundation of recovery. At the same time, a trait or condition might be considered more a form of individual difference that society needs to include and adapt to, in which case a mentalist attitude might be associated with assumptions and prejudices about what constitutes normal society and who is deserving of adaptations, support, or consideration.

Institutional discrimination

Offensive and injurious practices may be integrated into clinical procedures, to the point where professionals no longer recognize them as such, in what has been described as a form of institutional discrimination.

An institutional label

This may be apparent in physical separation, including separate facilities or accommodation, or in lower standards for some than others. Mental health professionals may find themselves drawn into systems based on bureaucratic and financial imperatives and social control, resulting in alienation from their original values, disappointment in "the system", and adoption of the cynical, mentalist beliefs that may pervade an organization. However, just as employees can be dismissed for disparaging sexual or ethnic remarks, it is argued that staff who are entrenched in negative stereotypes, attitudes, and beliefs about those labeled with mental disorders need to be removed from service organizations. A related theoretical approach, known as expressed emotion, has also focused on negative interpersonal dynamics relating to care givers, especially within families. However, the point is also made in such views that institutional and group environments can be challenging from all sides, and that clear boundaries and rights are required for everyone.

The mental health professions have themselves been criticised. While social work (also known as clinical social work) has appeared to have more potential than others to understand and assist those using services, and has talked a lot academically about anti-oppressive practice intended to support people facing various -isms, it has allegedly failed to address mentalism to any significant degree. The field has been accused, by social work professionals with experience of using services themselves, of failing to help people identify and address what is oppressing them; of unduly deferring to psychiatric or biomedical conventions particularly in regard to those deemed most unwell; and of failing to address its own discriminatory practices, including its conflicts of interest in its official role aiding the social control of patients through involuntary commitment.

In the "user/survivor" movement in England, Pete Shaughnessy, a founder of mad pride, concluded that the National Health Service is "institutionally mentalist and has a lot of soul searching to do in the new Millennium", including addressing the prejudice of its office staff. He suggested that when prejudice is applied by the very professionals who aspire to eradicate it, it raises the question of whether it will ever be eradicated. Shaughnessy committed suicide in 2002.

The psychiatric survivors movement has been described as a feminist issue, because the problems it addresses are "important for all women because mentalism acts as a threat to all women" and "mentalism threatens women's families and children." A psychiatric survivor and professional has said that "Mentalism parallels sexism and racism in creating an oppressed underclass, in this case of people who have received psychiatric diagnosis and treatment". She reported that the most frequent complaint of psychiatric patients is that nobody listens, or only selectively in the course of trying to make a diagnosis.

On a society-wide level, mentalism has been linked to people being kept in poverty as second class citizens; to employment discrimination keeping people living on handouts; to interpersonal discrimination hindering relationships; to stereotypes promoted through the media spreading fears of unpredictability and dangerousness; and to people fearing to disclose or talk about their experiences.

The legal system

With regard to legal protections against discrimination, mentalism may only be covered under general frameworks such as the disability discrimination acts that are in force in some countries, and which require a person to say that they have a disability and to prove that they meet the criteria.

In terms of the legal system itself, the law is traditionally based on technical definitions of sanity and insanity, and so the term "sanism" may be used in response. The concept is well known in the US legal community, being referred to in nearly 300 law review articles between 1992 and 2013, though is less well known in the medical community.

Michael Perlin, Professor of Law at New York Law School, has defined sanism as "an irrational prejudice of the same quality and character as other irrational prejudices that cause and are reflected in prevailing social attitudes of racism, sexism, homophobia, and ethnic bigotry that permeates all aspects of mental disability law and affects all participants in the mental disability law system: litigants, fact finders, counsel, and expert and lay witnesses."

Perlin notes that sanism affects the theory and practice of law in largely invisible and socially acceptable ways, based mainly on "stereotype, myth, superstition, and deindividualization." He believes that its "corrosive effects have warped involuntary civil commitment law, institutional law, tort law, and all aspects of the criminal process (pretrial, trial and sentencing)." According to Perlin, judges are far from immune, tending to reflect sanist thinking that has deep roots within our culture. This results in judicial decisions based on stereotypes in all areas of civil and criminal law, expressed in biased language and showing contempt for mental health professionals. Moreover, courts are often impatient and attribute mental problems to "weak character or poor resolve".

Sanist attitudes are prevalent in the teaching of law students, both overtly and covertly, according to Perlin. He notes that this impacts on the skills at the heart of lawyering such as "interviewing, investigating, counseling and negotiating", and on every critical moment of clinical experience: "the initial interview, case preparation, case conferences, planning litigation (or negotiation) strategy, trial preparation, trial and appeal."

There is also widespread discrimination by jurors, who Perlin characterizes as demonstrating "irrational brutality, prejudice, hostility, and hatred" towards defendants where there is an insanity defence. Specific sanist myths include relying on popular images of craziness; an 'obsession' with claims that mental problems can be easily faked and experts duped; assuming an absolute link between mental illness and dangerousness; an 'incessant' confusion and mixing up of different legal tests of mental status; and assuming that defendants acquitted on insanity defenses are likely to be released quickly. Although there are claims that neuroimaging has some potential to help in this area, Perlin concludes that it is very difficult to weigh the truth or relevance of such results due to the many uncertainties and limitations, and as it may be either disregarded or over-hyped by scientists, lawyers or in the popular imagination. He believes "the key to an answer here is a consideration of sanism", because to a great extent it can "overwhelm all other evidence and all other issues in this conversation". He suggests that "only therapeutic jurisprudence has the potential power to 'strip the sanist facade'."

Perlin has suggested that the international Convention on the Rights of Persons with Disabilities is a revolutionary human rights document which has the potential to be the best tool to challenge sanist discrimination.

He has also addressed the topic of sanism as it affects which sexual freedoms or protections are afforded to psychiatric patients, especially in forensic facilities.

Sanism in the legal profession can affect many people in communities who at some point in their life struggle with some degree of mental health problems, according to Perlin. This may unjustly limit their ability to legally resolve issues in their communities such as: "contract problems, property problems, domestic relations problems, and trusts and estates problems."

Susan Fraser, a lawyer in Canada who specializes in advocating for vulnerable people, argues that sanism is based on fear of the unknown, reinforced by stereotypes that dehumanize individuals. She argues that this causes the legal system to fail to properly defend patients' rights to refuse potentially harmful medications; to investigate deaths in psychiatric hospitals and other institutions in an equal way to others; and to fail to properly listen to and respect the voices of mental health consumers and survivors.

In education

Similar issues have been identified by Perlin in how children are dealt with in regard to learning disabilities, including in special education. In any area of law, he points out, two of the most common sanist myths are presuming that persons with mental disabilities are faking, or that such persons would not be disabled if they only tried harder. In this particular area, he concludes that labeled children are stereotyped in a process rife with racial, class and gender bias. Although intended to help some children, he contends that in reality it can be not merely a double-edged sword but a triple, quadruple or quintuple edged sword. The end result of sanist prejudices and misconceptions, in the context of academic competition, is that "we are left with a system that is, in many important ways, stunningly incoherent".

Multiple discriminations

A spiral of oppression experienced by some groups in society has been identified. Firstly, oppressions occur on the basis of perceived or actual differences (which may be related to broad group stereotypes such as racism, sexism, classism, ageism, homophobia etc.). This can have negative physical, social, economic and psychological effects on individuals, including emotional distress and what might be considered mental health problems. Then, society's response to such distress may be to treat it within a system of medical and social care rather than (also) understanding and challenging the oppressions that gave rise to it, thus reinforcing the problem with further oppressive attitudes and practices, which can lead to more distress, and so on in a vicious cycle. In addition, due to coming into contact with mental health services, people may become subject to the oppression of mentalism, since society (and mental health services themselves) have such negative attitudes towards people with a psychiatric diagnosis, thus further perpetuating oppression and discrimination.

People suffering such oppression within society may be drawn to more radical political action, but sanist structures and attitudes have also been identified in activist communities. This includes cliques and social hierarchies that people with particular issues may find very difficult to break into or be valued by. There may also be individual rejection of people for strange behavior that is not considered culturally acceptable, or alternatively insensitivity to emotional states including suicidality, or denial that someone has issues if they appear to act normally.

 

Neurodiversity

From Wikipedia, the free encyclopedia

https://en.wikipedia.org/wiki/Neurodiversity 

Autistic art representing the natural diversity of human minds.

The term neurodiversity refers to variation in the human brain regarding sociability, learning, attention, mood and other mental functions. It was coined in 1998 by sociologist Judy Singer, who helped popularize the concept along with journalist Harvey Blume. It emerged as a challenge to prevailing views that certain neurodevelopmental disorders are inherently pathological and instead adopts the social model of disability, in which societal barriers are the main contributing factor that disables people. This view is especially popular within the autism rights movement. The subsequent neurodiversity paradigm has been controversial among disability advocates, with opponents saying that its conceptualization doesn't reflect the realities of individuals who have high support needs.

History

The word neurodiversity is attributed to Judy Singer, a social scientist who has described herself as "likely somewhere on the autistic spectrum" and used the term in her sociology honors thesis published in 1999. The term represented a move away from previous "mother-blaming" theories about the cause of autism. Singer had been in correspondence with Blume as a result of their mutual interest in autism, and though he did not credit Singer, the word first appeared in print in an article by Blume in The Atlantic on September 30, 1998.

Some authors also credit the earlier work of autistic advocate Jim Sinclair in advancing the concept of neurodiversity. Sinclair was a principal early organizer of the international online autism community. Sinclair's 1993 speech, "Don't Mourn For Us", emphasized autism as a way of being: "It is not possible to separate the person from the autism." In a New York Times piece written by American journalist and writer Harvey Blume on June 30, 1997, Blume described the foundation of neurodiversity using the term "neurological pluralism". Blume was an early advocate who predicted the role the Internet would play in fostering the international neurodiversity movement.

The term "neurodiversity" has since been applied to other conditions and has taken on a more general meaning; for example, the Developmental Adult Neurodiversity Association (DANDA) in the UK encompasses developmental coordination disorder, ADHD, Asperger's syndrome, and related conditions.

Within disability rights movements

The neurodiversity paradigm was taken up first by individuals on the autism spectrum. Subsequently, it was applied to other neurodevelopmental conditions such as ADHD, developmental speech disorders, dyslexia, dyspraxia, dyscalculia, dysnomia, intellectual disability and Tourette syndrome, as well as schizophrenia, and some mental health conditions such as bipolarity, schizoaffective disorder, antisocial personality disorder, dissociative disorders, and obsessive–compulsive disorder. Neurodiversity advocates denounce the framing of autism, ADHD, dyslexia, and other neurodevelopmental disorders as requiring medical intervention to "cure" or "fix" them, and instead promote support systems such as inclusion-focused services, accommodations, communication and assistive technologies, occupational training, and independent living support. The intention is for individuals to receive support that honours authentic forms of human diversity, self-expression, and being, rather than treatment which coerces or forces them to adopt normative ideas of normality, or to conform to a clinical ideal.

Proponents of neurodiversity strive to reconceptualize autism and related conditions in society by the following measures: acknowledging that neurodiversity does not require a cure; changing the language from the current "condition, disease, disorder, or illness"-based nomenclature and "broaden[ing] the understanding of healthy or independent living"; acknowledging new types of autonomy; and giving non-neurotypical individuals more control over their treatment, including the type, timing, and whether there should be treatment at all.

A 2009 study separated 27 students (with autism, dyslexia, developmental coordination disorder, ADHD, and stroke), into two categories of self-view: "a 'difference' view—where neurodiversity was seen as a difference incorporating a set of strengths and weaknesses, or a 'medical/deficit' view—where neurodiversity was seen as a disadvantageous medical condition." They found that, although all of the students reported uniformly difficult schooling careers involving exclusion, abuse, and bullying, those who viewed themselves from a difference view (41% of the study cohort) "indicated higher academic self-esteem and confidence in their abilities and many (73%) expressed considerable career ambitions with positive and clear goals." Many of these students reported gaining this view of themselves through contact with neurodiversity advocates in online support groups.

A 2013 online survey, which aimed to assess conceptions of autism and neurodiversity, found that "a deficit-as-difference conception of autism suggests the importance of harnessing autistic traits in developmentally beneficial ways, transcending a false dichotomy between celebrating differences and ameliorating deficit."

Neurodiversity advocates point out that neurodiverse people often have exceptional abilities such as hyperfocus alongside their deficits. In particular, autistic people may have exceptional memory or even savant skills. In the autistic population, even those without savant skills are more likely than those in the general population to have exceptional knowledge or abilities in narrow domains.

Controversy

The neurodiversity paradigm is controversial in autism advocacy. The dominant paradigm is one which pathologizes human brains that diverge from those considered typical. From this perspective, these brains have medical conditions which should be treated.

A common criticism is that the neurodiversity paradigm is too widely encompassing and that its conception should exclude those whose functioning is more severely impaired. Autistic advocate and interdisciplinary educator Nick Walker offers the distinction that neurodivergencies refer specifically to "pervasive neurocognitive differences" that are "intimately related to the formation and constitution of the self," in contrast to medical conditions such as epilepsy.

Neurodiversity advocate John Elder Robison agrees that neurological difference may sometimes produce disability, but at the same time he argues that the disability caused by neurological difference may be inseparable from the strengths it provides. "99 neurologically identical people fail to solve a problem, it’s often the 1% fellow who’s different who holds the key. Yet that person may be disabled or disadvantaged most or all of the time. To neurodiversity proponents, people are disabled because they are at the edges of the bell curve; not because they are sick or broken." He therefore argues for the accommodation of neurological difference, while also recognizing that it can produce disability.

Psychiatric survivors movement

From Wikipedia, the free encyclopedia

https://en.wikipedia.org/wiki/Psychiatric_survivors_movement 

The psychiatric survivors movement (more broadly consumer/survivor/ex-patient movement) is a diverse association of individuals who either currently access mental health services (known as consumers or service users), or who are survivors of interventions by psychiatry, or who are ex-patients of mental health services.

The psychiatric survivors movement arose out of the civil rights movement of the late 1960s and early 1970s and the personal histories of psychiatric abuse experienced by some ex-patients. The key text in the intellectual development of the survivor movement, at least in the USA, was Judi Chamberlin's 1978 text, On Our Own: Patient Controlled Alternatives to the Mental Health System. Chamberlin was an ex-patient and co-founder of the Mental Patients' Liberation Front. Coalescing around the ex-patient newsletter Dendron, in late 1988 leaders from several of the main national and grassroots psychiatric survivor groups felt that an independent, human rights coalition focused on problems in the mental health system was needed. That year the Support Coalition International (SCI) was formed. SCI's first public action was to stage a counter-conference and protest in New York City, in May, 1990, at the same time as (and directly outside of) the American Psychiatric Association's annual meeting. In 2005 the SCI changed its name to MindFreedom International with David W. Oaks as its director.

Common themes are "talking back to the power of psychiatry", rights protection and advocacy, and self-determination. While activists in the movement may share a collective identity to some extent, views range along a continuum from conservative to radical in relation to psychiatric treatment and levels of resistance or patienthood.

History

Precursors

The modern self-help and advocacy movement in the field of mental health services developed in the 1970s, but former psychiatric patients have been campaigning for centuries to change laws, treatments, services and public policies. "The most persistent critics of psychiatry have always been former mental hospital patients", although few were able to tell their stories publicly or to openly confront the psychiatric establishment, and those who did so were commonly considered so extreme in their charges that they could seldom gain credibility. In 1620 in England, patients of the notoriously harsh Bethlem Hospital banded together and sent a "Petition of the Poor Distracted People in the House of Bedlam (concerned with conditions for inmates)" to the House of Lords. A number of ex-patients published pamphlets against the system in the 18th century, such as Samuel Bruckshaw (1774), on the "iniquitous abuse of private madhouses", and William Belcher (1796) with his "Address to humanity, Containing a letter to Dr Munro, a receipt to make a lunatic, and a sketch of a true smiling hyena". Such reformist efforts were generally opposed by madhouse keepers and medics.

In the late 18th century, moral treatment reforms developed which were originally based in part on the approach of French ex-patient turned hospital-superintendent Jean-Baptiste Pussin and his wife Margueritte. From 1848 in England, the Alleged Lunatics' Friend Society campaigned for sweeping reforms to the asylum system and abuses of the moral treatment approach. In the United States, The Opal (1851–1860) was a ten volume Journal produced by patients of Utica State Lunatic Asylum in New York, which has been viewed in part as an early liberation movement. Beginning in 1868, Elizabeth Packard, founder of the Anti-Insane Asylum Society, published a series of books and pamphlets describing her experiences in the Illinois insane asylum to which her husband had her committed.

Early 20th century

A few decades later, another former psychiatric patient, Clifford W. Beers, founded the National Committee on Mental Hygiene, which eventually became the National Mental Health Association. Beers sought to improve the plight of individuals receiving public psychiatric care, particularly those committed to state institutions. His book, A Mind that Found Itself (1908), described his experience with mental illness and the treatment he encountered in mental hospitals. Beers' work stimulated public interest in more responsible care and treatment. However, while Beers initially blamed psychiatrists for tolerating mistreatment of patients, and envisioned more ex-patient involvement in the movement, he was influenced by Adolf Meyer and the psychiatric establishment, and toned down his hostility as he needed their support for reforms. His reliance on rich donors and his need for approval from experts led him to hand over to psychiatrists the organization he helped establish. In the UK, the National Society for Lunacy Law Reform was established in 1920 by angry ex-patients sick of their experiences and complaints being patronisingly discounted by the authorities who were using medical "window dressing" for essentially custodial and punitive practices. In 1922, ex-patient Rachel Grant-Smith added to calls for reform of the system of neglect and abuse she had suffered by publishing "The Experiences of an Asylum Patient".

We Are Not Alone (WANA) was founded by a group of patients at Rockland State Hospital in New York (now the Rockland Psychiatric Center) in the mid to late 1940s, and continued to meet as an ex-patient group. Their goal was to provide support and advice and help others make the difficult transition from hospital to community. At this same time, a young social worker in Detroit, Michigan was doing some pioneering work with psychiatric patients from the “back wards” of Wayne County Hospital. Prior to the advent of psychotropic medication, patients on the “back wards” were generally considered to be "hopelessly sick." John H. Beard began his work on these wards with the conviction that these patients were not totally consumed by illness but retained areas of health. This insight led him to involve the patients in such normal activities as picnics, attending a baseball game, dining at a fine restaurant, and then employment. Fountain House had, by now, recognized that the experience of the illness, together with a poor or interrupted work history often denied members the opportunity to obtain employment. Many lived in poverty and never got the chance to even try working on a job.

The hiring of John H. Beard as Executive Director in 1955 changed all of that. The creation of what we now know to be Transitional Employment transformed Fountain House as many members began venturing from the clubhouse into real jobs for real wages in the community. Importantly, these work opportunities were in integrated settings and not just with other persons with disabilities. The concept of what was normal was pervasive in all of what Fountain House set out to do. Thus, Fountain House became a place of both social and vocational rehabilitation, addressing the disabilities that so often accompany having a serious mental illness and setting the wheels in motion for a life of recovery and not disability.

Originated by crusaders in periods of liberal social change, and appealing not so much to other sufferers as to elite groups with power, when the early reformer's energy or influence waned, mental patients were again mostly friendless and forgotten.

1950s to 1970s

The 1950s saw the reduction in the use of lobotomy and shock therapy. These used to be associated with concerns and much opposition on grounds of basic morality, harmful effects, or misuse. Towards the 1960s, psychiatric medications came into widespread use and also caused controversy relating to adverse effects and misuse. There were also associated moves away from large psychiatric institutions to community-based services (later to become a full-scale deinstitutionalization), which sometimes empowered service users, although community-based services were often deficient.

Coming to the fore in the 1960s, an anti-psychiatry movement challenged the fundamental claims and practices of mainstream psychiatry. The ex-patient movement of this time contributed to, and derived much from, antipsychiatry ideology, but has also been described as having its own agenda, described as humanistic socialism. For a time, the movement shared aims and practices with "radical therapists", who tended to be Marxist. However, the consumer/survivor/ex-patients gradually felt that the radical therapists did not necessarily share the same goals and were taking over, and they broke away from them in order to maintain independence.

By the 1970s, the women's movement, gay rights movement, and disability rights movements had emerged. It was in this context that former mental patients began to organize groups with the common goals of fighting for patients' rights and against forced treatment, stigma and discrimination, and often to promote peer-run services as an alternative to the traditional mental health system. Unlike professional mental health services, which were usually based on the medical model, peer-run services were based on the principle that individuals who have shared similar experiences can help themselves and each other through self-help and mutual support. Many of the individuals who organized these early groups identified themselves as psychiatric survivors. Their groups had names such as Insane Liberation Front and the Network Against Psychiatric Assault.

In 1971 the Scottish Union of Mental Patients was founded. In 1973 some of those involved founded the Mental Patients' Union in London.

Dorothy Weiner and about 10 others, including Tom Wittick, established the Insane Liberation Front in the spring of 1970 in Portland, Oregon. Though it only lasted 6 months, it had a notable influence in the history of North American ex-patients groups. News that former inmates of mental institutions were organizing was carried to other parts of North America. Individuals such as Howard Geld, known as Howie the Harp for his harmonica playing, left Portland where he been involved in ILF to return to his native New York to help found the Mental Patients Liberation Project in 1971. During the early 1970s, groups spread to California, New York, and Boston, which were primarily antipsychiatry, opposed to forced treatment including forced drugging, shock treatment and involuntary committal. In 1972, the first organized group in Canada, the Mental Patients Association, started to publish In A Nutshell, while in the US the first edition of the first national publication by ex-mental patients, Madness Network News, was published in Oakland, continuing until 1986.

Some all-women groups developed around this time such as Women Against Psychiatric Assault, begun in 1975 in San Francisco.

In 1978 Judi Chamberlin's book On Our Own: Patient Controlled Alternatives to the Mental Health System was published. It became the standard text of the psychiatric survivors movement, and in it Chamberlin coined the word "mentalism."

The major spokespeople of the movement have been described in generalities as largely white, middle-class and well-educated. It has been suggested that other activists were often more anarchistic and anti-capitalist, felt more cut off from society and more like a minority with more in common with the poor, ethnic minorities, feminists, prisoners & gay rights than with the white middle classes. The leaders were sometimes considered to be merely reformist and, because of their "stratified position" within society, to be uncomprehending of the problems of the poor. The "radicals" saw no sense in seeking solutions within a capitalist system that creates mental problems. However, they were united in considering society and psychiatric domination to be the problem, rather than people designated mentally ill.

Some activists condemned psychiatry under any conditions, voluntary or involuntary, while others believed in the right of people to undergo psychiatric treatment on a voluntary basis. Voluntary psychotherapy, at the time mainly psychoanalysis, did not therefore come under the same severe attack as the somatic therapies. The ex-patients emphasized individual support from other patients; they espoused assertiveness, liberation, and equality; and they advocated user-controlled services as part of a totally voluntary continuum. However, although the movement espoused egalitarianism and opposed the concept of leadership, it is said to have developed a cadre of known, articulate, and literate men and women who did the writing, talking, organizing, and contacting. Very much the product of the rebellious, populist, anti-elitist mood of the 1960s, they strived above all for self-determination and self-reliance. In general, the work of some psychiatrists, as well as the lack of criticism by the psychiatric establishment, was interpreted as an abandonment of a moral commitment to do no harm. There was anger and resentment toward a profession that had the authority to label them as mentally disabled and was perceived as infantilizing them and disregarding their wishes.

1980s and 1990s

By the 1980s, individuals who considered themselves "consumers" of mental health services rather than passive "patients" had begun to organize self-help/advocacy groups and peer-run services. While sharing some of the goals of the earlier movement, consumer groups did not seek to abolish the traditional mental health system, which they believed was necessary. Instead, they wanted to reform it and have more choice. Consumer groups encouraged their members to learn as much as possible about the mental health system so that they could gain access to the best services and treatments available. In 1985, the National Mental Health Consumers' Association was formed in the United States.

A 1986 report on developments in the United States noted that "there are now three national organizations ... The ‘conservatives’ have created the National Mental Health Consumers' Association ... The ‘moderates’ have formed the National Alliance of Mental Patients ... The ‘radical’ group is called the Network to Abolish Psychiatry". Many, however, felt that they had survived the psychiatric system and its "treatments" and resented being called consumers. The National Association of Mental Patients in the United States became the National Association of Psychiatric Survivors. "Phoenix Rising: The Voice of the Psychiatrized" was published by ex-inmates (of psychiatric hospitals) in Toronto from 1980 to 1990, known across Canada for its antipsychiatry stance.

In late 1988, leaders from several of the main national and grassroots psychiatric survivor groups decided an independent coalition was needed, and Support Coalition International (SCI) was formed in 1988, later to become MindFreedom International. In addition, the World Network of Users and Survivors of Psychiatry (WNUSP), was founded in 1991 as the World Federation of Psychiatric Users (WFPU), an international organisation of recipients of mental health services.

An emphasis on voluntary involvement in services is said to have presented problems to the movement since, especially in the wake of deinstitutionalization, community services were fragmented and many individuals in distressed states of mind were being put in prisons or re-institutionalized in community services, or became homeless, often distrusting and resisting any help.

Science journalist Robert Whitaker has concluded that patients rights groups have been speaking out against psychiatric abuses for decades - the torturous treatments, the loss of freedom and dignity, the misuse of seclusion and restraints, the neurological damage caused by drugs - but have been condemned and dismissed by the psychiatric establishment and others. Reading about the experiences they suffered through has been described as comparable to reading the stories of Holocaust survivors. Recipients of mental health services demanded control over their own treatment and sought to influence the mental health system and society's views.

The movement today

In the United States, the number of mental health mutual support groups (MSG), self-help organizations (SHO) (run by and for mental health consumers and/or family members) and consumer-operated services (COS) was estimated in 2002 to be 7,467. In Canada, CSI's (Consumer Survivor Initiatives) are the preferred term. "In 1991 Ontario led the world in its formal recognition of CSI's as part of the core services offered within the mental health sector when it began to formally fund CSI's across the province. Consumer Survivor Initiatives in Ontario Building an Equitable Future' (2009) pg 7. The movement may express a preference for the "survivor" label over the "consumer" label, with more than 60 percent of ex-patient groups reported to support anti-psychiatry beliefs and considering themselves to be "psychiatric survivors." There is some variation between the perspective on the consumer/survivor movement coming from psychiatry, anti-psychiatry or consumers/survivors themselves.

The most common terms in Germany are "Psychiatrie-Betroffene" (people afflicted by/confronted with psychiatry) and "Psychiatrie-Erfahrene" (people who have experienced psychiatry). Sometimes the terms are considered as synonymous but sometimes the former emphasizes the violence and negative aspects of psychiatry. The German national association of (ex-)users and survivors of psychiatry is called the Bundesverband Psychiatrie-Erfahrener (BPE).

There are many grassroots self-help groups of consumers/survivors, local and national, all over the world, which are an important cornerstone of empowerment. A considerable obstacle to realizing more consumer/survivor alternatives is lack of funding. Alternative consumer/survivor groups like the National Empowerment Center in the US which receive public funds but question orthodox psychiatric treatment, have often come under attack for receiving public funding and been subject to funding cuts.

As well as advocacy and reform campaigns, the development of self-help and user/survivor controlled services is a central issue. The Runaway-House in Berlin, Germany, is an example. Run by the Organisation for the Protection from Psychiatric Violence, it is an antipsychiatric crisis centre for homeless survivors of psychiatry where the residents can live for a limited amount of time and where half the staff members are survivors of psychiatry themselves. In Helsingborg, Sweden, the Hotel Magnus Stenbock is run by a user/survivor organization "RSMH" that gives users/survivors a possibility to live in their own apartments. It is financed by the Swedish government and run entirely by users. Voice of Soul is a user/survivor organization in Hungary. Creative Routes is a user/survivor organization in London, England, that among other support and advocacy activities puts on an annual "Bonkersfest".

WNUSP is a consultant organization for the United Nations. After a "long and difficult discussion", ENUSP and WNUSP (European and World Networks of Users and Survivors of Psychiatry) decided to employ the term (ex-)users and survivors of psychiatry in order to include the identities of the different groups and positions represented in these international NGOs. WNUSP contributed to the development of the UN's Convention on the Rights of Persons with Disabilities and produced a manual to help people use it entitled "Implementation Manual for the United Nations Convention on the Rights of Persons with Disabilities", edited by Myra Kovary. ENUSP is consulted by the European Union and World Health Organization.

In 2007 at a Conference held in Dresden on "Coercive Treatment in Psychiatry: A Comprehensive Review", the president and other leaders of the World Psychiatric Association met, following a formal request from the World Health Organization, with four representatives from leading consumer/survivor groups.

The National Coalition for Mental Health Recovery (formerly known as National Coalition for Mental Health Consumer/Survivor Organizations) campaigns in the United States to ensure that consumer/survivors have a major voice in the development and implementation of health care, mental health, and social policies at the state and national levels, empowering people to recover and lead a full life in the community.

The United States Massachusetts-based Freedom Center provides and promotes alternative and holistic approaches and takes a stand for greater choice and options in treatments and care. The center and the New York-based Icarus Project (which does not self-identify as a consumer/survivor organization but has participants that identify as such) have published a Harm Reduction Guide To Coming Off Psychiatric Drugs and were recently a featured charity in Forbes business magazine.

Mad pride events, organized by loosely connected groups in at least seven countries including Australia, South Africa, the United States, Canada, the United Kingdom and Ghana, draw thousands of participants. For some, the objective is to continue the destigmatization of mental illness. Another wing rejects the need to treat mental afflictions with psychotropic drugs and seeks alternatives to the "care" of the medical establishment. Many members of the movement say they are publicly discussing their own struggles to help those with similar conditions and to inform the general public.

Survivor David Oaks, Director of MindFreedom, hosted a monthly radio show and the Freedom Center initiated a weekly FM radio show now syndicated on the Pacifica Network, Madness Radio, hosted by Freedom Center co-founder Will Hall.

A new International Coalition of National Consumer/User Organizations was launched in Canada in 2007, called Interrelate.

Impact

Research into consumer/survivor initiatives (CSIs) suggests they can help with social support, empowerment, mental wellbeing, self-management and reduced service use, identity transformation and enhanced quality of life. However, studies have focused on the support and self-help aspects of CSIs, neglecting that many organizations locate the causes of members’ problems in political and social institutions and are involved in activities to address issues of social justice.

A 2006 series of studies in Canada compared individuals who participated in CSIs with those who did not. The two groups were comparable at baseline on a wide range of demographic variables, self-reported psychiatric diagnosis, service use, and outcome measures. After a year and a half, those who had participated in CSIs showed significant improvement in social support and quality of life (daily activities), less days of psychiatric hospitalization, and more were likely to have stayed in employment (paid or volunteer) and/or education. There was no significant difference on measures of community integration and personal empowerment, however. There were some limitations to the findings; although the active and nonactive groups did not differ significantly at baseline on measures of distress or hospitalization, the active group did have a higher mean score and there may have been a natural pattern of recovery over time for that group (regression to the mean). The authors noted that the apparent positive impacts of consumer-run organizations were achieved at a fraction of the cost of professional community programs.

Further qualitative studies indicated that CSIs can provide safe environments that are a positive, welcoming place to go; social arenas that provide opportunities to meet and talk with peers; an alternative worldview that provides opportunities for members to participate and contribute; and effective facilitators of community integration that provide opportunities to connect members to the community at large. System-level activism was perceived to result in changes in perceptions by the public and mental health professionals (about mental health or mental illness, the lived experience of consumer/survivors, the legitimacy of their opinions, and the perceived value of CSIs) and in concrete changes in service delivery practice, service planning, public policy, or funding allocations. The authors noted that the evidence indicated that the work benefits other consumers/survivors (present and future), other service providers, the general public, and communities. They also noted that there were various barriers to this, most notably lack of funding, and also that the range of views represented by the CSIs appeared less narrow and more nuanced and complex than previously, and that perhaps the consumer/survivor social movement is at a different place than it was 25 years ago.

A significant theme that has emerged from consumer/survivor work, as well as from some psychiatrists and other mental health professionals, has been a recovery model which seeks to overturn therapeutic pessimism and to support sufferers to forge their own personal journey towards the life they want to live; some argue however that it has been used as a cover to blame people for not recovering or to cut public services.

There has also been criticism of the movement. Organized psychiatry often views radical consumerist groups as extremist, as having little scientific foundation and no defined leadership, as "continually trying to restrict the work of psychiatrists and care for the seriously mentally ill", and as promoting disinformation on the use of involuntary commitment, electroconvulsive therapy, stimulants and antidepressants among children, and neuroleptics among adults. However, opponents consistently argue that psychiatry is territorial and profit-driven and stigmatizes and undermines the self-determination of patients and ex-patients The movement has also argued against social stigma or mentalism by wider society.

Well-positioned forces in the US, led by figures such as psychiatrists E. Fuller Torrey and Sally Satel, and some leaders of the National Alliance on Mental Illness, have lobbied against the funding of consumer/survivor groups that promote antipsychiatry views or promote social and experiential recovery rather than a biomedical model, or who protest against outpatient commitment. Torrey has said the term "psychiatric survivor" used by ex-patients to describe themselves is just political correctness and has blamed them, along with civil rights lawyers, for the deaths of half a million people due to suicides and deaths on the street. His accusations have been described as inflammatory and completely unsubstantiated, however, and issues of self-determination and self-identity said to be more complex than that.