Introduction: Psychiatry and "Survivors"

In January-February 1997, there was an agitated discussion on the Radical Psychology Network concerning the usage of forced ECT and other forced medication in psychiatry. I will try to summarize in this paper some the questions brought up and the goals proclaimed.

In general, the current situation in psychiatry looks as follows:

There are psychiatric hospitals where people are treated according to the practices established, which implies possible application of strong drugs and electroconvulsive therapy (ECT) if the case is considered serious enough.

A number of problems emerge in this connection:

1. Diagnosing people as "mentally sick" may be quite dubious, depending on economic and political interests rather than on medical considerations proper. Mental patients may be placed in a hospital by mistake, neglect or malice, which is a hard experience for a person, leading to the development of true psychological misbalance.

2. The adequate level of treatment is difficult to determine in psychiatry, especially when higher mental functions are concerned. There may be no distinct boundary between persisting malady and convinced non-conformism, and the diagnosis may be biased due to the very fact of the patient's placement in a mental hospital.

3. Doctors are never free from the social influence when deciding on the treatment to choose. Local economy, politics and social climate may distort medical judgment, so that medication may be excessive and involve various side effects.

4. The qualification of the psychiatrist is crucial for the right diagnosis and treatment; the strong methods of medication may be highly destructive in unqualified application.

Though many people who received psychiatric treatment were feeling better and could return to normal life, there has always been a doubt as to whether such people should be considered sane enough, and whether the medical treatment didn't make them less "human". Much of this fear is due to the commonly prejudiced attitude to the "mentally ill", which is expressed in many abusive words applied to such people: "lunatic", "cracked", "crazy", "mad" etc. There is a typical parallel in the common notion: one who had an arm amputated thus became an invalid for the rest of one's life—in the same way, one treated with such destructive procedures as strong drugs or ECT might become a kind of "mental invalid", requiring more caution in any communication since nobody can know exactly what is to be expected from a person "injured" that way.

On the other side, the former mental patients put in an isolation because of that common prejudice are apt to yield to the social pressure and blame psychiatrists for the harm they presumably made to their patients. Since social activism has become popular all over the world, former mental patients start to call themselves "survivors" and organize into numerous groups fighting against psychiatry in general or some of its practices.

Several levels could be distinguished in this opposition.

The most "radical" part of "survivors" say that psychiatry is mass murder and demand the abolishment of all the means of medication available to psychiatrists, and thus psychiatry itself. Also, there are "specialized" movements of this kind aiming to banning (or cutting funds on) some particular procedure (e.g. ECT).

Less tough groups of "survivors" are not demanding the complete abolishment of psychiatry (or some of its methods), but rather restricting its applications, subduing it to a kind of public control preventing "forced" medication. Some psychiatrists sympathize to this movement considering it quite "democratic" in nature.

A lower grade of tension is associated with the activism suggesting that "forced" medication may take place under strictly controlled conditions only, and by specially trained personal, qualified enough to reduce the possible harm of the procedure to the least degree achievable. The specialists usually agree with such statements, though there are often hidden differences in the attitude.

Some "survivor" groups shift the accent to the social premises of their relative isolation and speak of a complex rehabilitation system for mental patients demanding that the others treat them like ordinary people.

I will briefly discuss the problems arising with each of these types of "survivor" activism in turn.

Medical Paradigm?

The anti-psychiatry movement reflects, though in a somewhat exaggerated way, a number of objective factors pertaining to any medication, and psychiatry in particular. Thus, the positions of the doctor and the patient are objectively opposite, which may grow into a kind of antagonism under definite social conditions. The polarity of the positions explains the common observation that doctors are often unable to cure themselves and have to consult other doctors when feeling bad. In the conditions of all-penetrating division of labor characteristic of capitalist society, the relations between the doctor and the patient become formal (or even codified) thus transforming into a psychological game (as described by E. Berne), with all its conflicts and goal distortion.

Another point is that any categorization is socially biased, and any diagnosis will reflect both objective symptoms and the society's attitude to them. So, what is considered quite normal in one society may be considered as illness in another, or as a crime in yet another one. The example of alcoholism is well-known. Some narcotic drugs are near to be legalized in many countries, thus changing the very notion of drug dependence. The situation is much more complex with mental deviations, and psychiatric diagnosis can always be questioned, with no universally accepted answer possible. For example, suicidal ideation may be treated as anti-social act, so that forced medication shall be prescribed at any suspicion. In another social environment, suicide may be a normal way of quitting one's life and be supported with officially provided procedures (hara-kiri in Japan, bath ritual in the Ancient Rome, parent smothering at chukchi, euthanasia etc.).

The problem is that social regulation may contradict to the interests of an individual, suppressing personal inclinations to preserve the social structure. Thus, in class societies, suicide is rarely allowed for the representatives of the lower classes, since the well-being of the ruling class is based on mass exploitation, while suicide would allow the exploited escape from working for their master. That is why the ideas of the higher value of human life and post-mortem punishment for "bad" behavior are being implanted in the minds of the people.

In the individual consciousness, the opposition of the person and the society is reflected as oppression, with some social layers forcing the individual to the alien ways. No wonder that such oppressed individuals use to unite in defending themselves from whom they find guilty in their hard experiences. However, individual (and group) consciousness is not necessarily correct in detecting the cause of the trouble, and attacks people and things that are just superficially related to the problem. Thus, anti-psychiatry movement blames psychiatrists where it should be concerned with the economic and social issues determining their work. No wonder that psychiatrists try to defend themselves from the unjust criticizing, and become involved in a team game against their patients.

Another aspect of it is whether there is such thing as (mental) disease, or it is just an artifact of the medical paradigm, based on the rigid opposition of illness and health. One might argue that health is very individual, and strong variations in mentality should not be called a disease. However, the argument becomes meaningless if restricted to the parameters of the individual only—the solution is to look at the individual's functionality within the society. If one is unable to do what is socially expected under given economic and social conditions, this is what will be called a deviation from normality; if such deviation becomes socially destructive, it is called disease. For example, one's inability to do one's work (imposed by the society) is a sign of illness; one may go on doing what one is obliged to do, despite the bad headache — then one will be considered as slightly uneasy but not ill.

Note that there is a difference between "illness" and "feeling sick". The latter is subjective, and may be quite uncorrelated with social performance. One may have to work feeling extremely bad—on the contrary, one may feel fine while the society would diagnose a dangerous disease (which is especially characteristic of psychiatry). If medication is applied to such subjectively healthy person, it will inevitably be felt as repressive, and the treatment will appear "forced". Under different circumstances, subjective attitude to similar methods may be different, and hence any judgment should keep within the appropriate cultural limits, so that one would not project one's own experience onto a quite different mentality.

Forced Medication?

As indicated, there are no absolute criteria of forced treatment. Classifying a particular case as forced reflects the discrepancy between the social norm and the subjective conceptions due to inadequacy of vertical relations in the hierarchy of subjectivity, from the individual, through groups, social layers, classes, nations, up to the humanity as a whole. Forced medication is a manifestation of a more general feature of the respective level of sociality: when society is broken into numerous groups with opposite interests, and the dominant way of aggregating them into the whole is competition and fight, medicine cannot be other than forcing the attitude of one social group onto the others. Antagonistic society implies antagonistic medicine.

Since capitalism is based on the universal division of labor, it makes forced medication as universal. The caste of professionals won't listen to the opinions of "non-experts", and the patient would not be allowed to doubt the regimen prescribed. When knowledge and skill become the articles of trade, they serve to support the lives of doctors rather than of their patients, which are treated as raw material for making the doctor's money. One cannot expect much compassion and kindness to the patient, and tolerance to the patient's peculiar views. This means that any medication tends to be forced under capitalism.

The "survivor" activists fighting against "forced" medication appeal to personal freedom as an argument. Conscious people should decide themselves which way of treatment they would prefer, provided the agreement about the basic social values is achieved, and the disease can be distinguished from the normality in a generally accepted way. Beside the already mentioned relativity of such a distinction, there are many more narrow places in this approach.

First, an individual who never studied medicine can hardly make a conscious choice, and the only criteria left are economic considerations, common prejudices, or personal sympathies. Thus, poor people will definitely prefer a cheaper (though not necessarily adequate) treatment, while the rich are socially compelled to use more expensive (though quite inefficient) drugs or procedures. The general medical ignorance serves for the benefit of numerous healers, sorcerers, shamans, exorcists, miracle-workers and God's fools. Serious medicine is less spectacular than an occult show, and hence less convincing for an ignorant person. To compete on the market, doctors have to make show of their work, thus wasting the resources that could be better spared for the people in need. Thus the health of the society gets eroded. This is just the other side of bourgeois democracy, which gives the means control into the hands of those who look better, despite of utter incompetence and corruption; virtually, a "good look" is a matter of money.

One more difficulty is that the ability of judgment is tightly bound to health. People are not abstract spirits observing the body from the holy heights. The state of the body affects feelings and reasoning. For example, one may perfectly know that a bad tooth is dangerous and requires medication—but the fear of pain would not let them go to the dentist, until the toothache overweighs the pain of treatment. The more so with psychiatry, where therapy is often more distressing for the individual than the symptoms of disease.

Yes, medication may cause pain—but it often helps. So people have to be forced into medical treatment, and they enjoy health after it. Of course, the appearance of more efficient and safe methods of medication would lead to less fears and more consent from the patients. Meanwhile, numerous means of masking the negative sides of treatment are being applied, from autosuggestion to narcotic drugs. Hardly anybody will decline narcotizing on the operation table just because the drugs are altering the normal functioning of the organism.

If the patient is unable to understand their actual condition, their consent to treatment is worthless. Moreover, because of the dependence of judgment on the state of the organism, it could be dangerous for the patient if the doctor asked their opinion before doing anything. Is it fare to reload the burden of decision to a sick person and thus free doctors from responsibility? Virtually, doctors are to heal people—this is their job. The patients must be brought into treatment first of all, and be relieved of their sickness before being asked of anything. When a surgeon has to amputate a leg of an unknown person delivered in the unconscious state, it is considerations of the person's survival that are of importance, and never one's consent to become an invalid. Disasters don't ask people when to occur.

The ability of the patient to give conscious consent may strongly depend on their social status as well. Thus, in most societies children have no voice in deciding their fate, and hence all treatment on children is forced. Again, the negative sides may be masked—but the matter is still the same: children are made to accept medication. In general, this is merely a part of the acculturation process, when a child is forced to do a great many of things, like wearing the clothes, using the toilet, eating with forks and spoons, going to school etc.

Now, the question becomes: what does it it mean to be forced or coerced into anything? There are various grades of coercion in everything people shall do as the members of the group, social layer, or ethnos. It is the matter of economic and social organization that local or global acculturation would lose its forced character and become a smooth process—though the smoothness can hardly ever be absolute, due to the dialectical nature of any development. One of the manifestations of free will may be a deliberate limitation of free will, allowing for "forced" treatment when it is socially required.

Public Control?

In an imperfect society, when the individual is subdued to the social demands and forced to act in accordance with the regulations brought on them from "above", medicine cannot avoid forced treatment, which can be easily turned into abuse. The patient comes (or is made to come) to a doctor for help, and the position of need makes a person vulnerable, since all the means of satisfying that need are monopolized by a group of professionals. The patient has to be somehow protected from the possible abusive use of what normally is used for therapeutic purposes.

What kind of a problem is it? Its minor part is the abuse from ill-minded doctors, seeking for profit, following the perverted sense of caste honesty, or just indifferent to the patient's feelings (which is a kind of professional illness in long-experienced practitioners). The criminal use of various kinds of medication belongs to this category as well. Actually, this side of medication abuse is common to the abusive use of anything else, since anything that is alienated from the people in the ill society can be used against them. Psychiatry can also used in a criminal way—though the notion of "crime" completely depends on the kind of society. However, forced psychiatric treatment is much less efficient as a means of control than, say, forced drug dependence or the threat of death. So, it can hardly be very frequent in practice—hence it becomes more sensational, and more fit for manipulating public opinion.

Much more typical (and more dangerous) is unintended abuse, often related to indirect coercion. Thus, if medication is to be paid for, those who do not have enough money are forced to stick to the only source of medical treatment available, and they have to obey any prescriptions just from the fear of all treatment and support being withdrawn. Most medication may seem quite voluntary on the face of it, with a deep feeling of abuse beneath. This feeling may be inadequate, reflecting the vulnerability of the patient's position rather than any actual malpractice: the powerless may easily feel forced to make decisions they don't understand. Still, it makes the claims of more control on forced medication more attractive to the poorer layers of society.

Though many practitioners are honest enough and really willing to help people, they cannot ignore social pressure and act as they feel right, discarding the other's opinions. This pressure may be due to either the tradition of treatment or the prejudices of the patient. Risk of being blamed for malpractice for not doing like other specialists do is more strong for psychiatrists, though it is quite real for any other medical profession too, since tradition still lies in the foundation of modern medicine. Also, there are a number of medical schools strictly controlling the activities of their members. Doctors have to live and support their families—and they cannot be expected to sacrifice their well-being for the interests of a stranger. On the other side, the patients often have some conceptions about how they should be treated; these common conceptions are usually induced by the current medical practice as well as by the advertising by the competing companies producing drugs, medical equipment etc. If a doctor does not prescribe what has been expected, he/she may be suspected in following a wrong line, and all the treatment would seem forced, without any connection to its actual efficiency.

Yet another source of indirect coercion is the dependence of hospitals on external funding. Thus, if a hospital is sponsored by a pharmaceutical company, the medical personal has to preferably use the medicines produced by this company, being just a part of its advertising campaign. The same effect can be observed when there exist restrictions on material provision, staff formation etc.

Is there any way to establish an efficient control over forced medication? This idea is most popular in the old capitalist countries, where centuries of propaganda have formed public mentality which utterly cannot conceive anything beyond the bourgeois democracy. The democratic idea of coercion control is to establish one more system of coercion that would neutralize the possible malpractice in medicine; the rule is: "like cures like", and many bad things are hoped to balance each other so that the result would be at least tolerable.

Different levels of coercion control system could be considered. Thus, common people are accustomed to expect that the state would guarantee their "human rights" and take over the coercion control. This appears to introduce no new social force, since the state is an apparatus of coercion already, and it could just have one more task to perform. Within certain limits, the state may defend the rights of its citizens (by the expense of the rights of all the non-citizens, of course). However, the main purpose of the bourgeois state is quite different from satisfying the needs of the people, and it would much more readily used in the interests of the competing groups practicing forced treatment, rather than for protecting the interests of the patients. In particular, any legal regulations and court proceedings are sure to mainly serve the richer part of the society, and ignore the poorer part. Since the state is mainly the mechanism of preserving the already existing social organization, it would rather stay on the side of professional castes, supporting their self-determination by the expense of the clients' health.

On the lower level, the activists often suggest the creation of various control organizations (employing themselves as "true experts"). Such commissions would consider every particular case and sanction forced medication when it is really needed. The application of potentially harmful methods of medication would thus be restricted, and the negative interference of the state would be neutralized in a part. The control organizations are conceived as open for the wide public and ruled by it, in the interests of all the people.

However, such institutionalized control would mean just one more social force, which should be somehow controlled too, the chain of mutually controlling organizations unfolding to infinity. Nothing prevents the formation of numerous commissions each one pretending to be the highest instance and arguing for that right with the rest of the world. Small specialized organizations are almost sure to fall under the influence of more powerful and diversified social groups, becoming mere mouthpiece of their opinions.

Another side of it is the lack of competent judgment. Public control in the conditions of the division of labor would necessarily mean the dominance of incompetent views of the crowd over the sober professional consideration. Professionals would hardly be any assistance for the organizations created in the opposition to them, and the knowledge and experience they monopolize would not be shared with the public controls. Of course, there may be talented amateurs who would study medicine to be competent enough; still, they will always have a choice between either admitted to the practice of medication and the experience associated with it (thus becoming the representatives of the medical caste), or remaining only partially educated and hence incompetent. Typically, the public commissions are a field for a wide employment of the numerous "survivors", bringing in their subjective feelings and exaggerated apprehensions as the basis for decision making.

One more level of public control is often discussed, delegating the right of decision to the individuals. It is often argued that conscious clients should be partners of the doctor in medical treatment, declining all the solutions that do not satisfy them. The advocates of this line admit that the disease may sometimes lead to the loss of self-control in the patient, so that one cannot decide for oneself; in this case, the relatives or other legal guardians of that person should have the casting vote in forcing a medication on him/her.

This attitude is most attractive to many people, since it plays on their self-importance, and self-conceit. However, few people can be considered as conscious enough in making decisions where they know very little or nothing at all. Incompetence combined with too much self-esteem often leads to the self-assertive behavior of the patient tempting the doctor to force a severer treatment on them. Since the family relations are tightly linked to economic interests in the capitalist society, the relatives of the patient can rarely be expected to follow the patient's interests. Rather, they would try to arrange their own affairs, and may insist on forced medication driven by economic considerations or hidden conflicts. Thus, husbands may have their wives electroshocked for "misbehavior", the aged parents may be put into asylum by their children for "senile disorders", and inversely, the parents may have their children drugged for their "strangeness", etc. In the world where money is the supreme power the individuals cannot trust each other enough.

Rehabilitation?

Any medication may be harmful due to the unexpected side effects, the incompetence or neglect of a specialist, or just the insufficient development of medicine and the absence of less traumatic methods. Also, forced treatment is a reality of contemporary world, and one can never be sure that it has been the last resort indeed. So, the former patients often cannot enter the "normal" life smoothly enough, especially, if a destructive therapy has been used on them. This may be either temporary awkwardness eliminated by adaptation—or a permanent deficiency, invalidation. In the capitalist society, where an individual is evaluated depending on his or her ability to produce values that could be appropriated by the bourgeoisie, any deficiency is considered as lowering the "market price" of the individual, so that the former patients become less valuable for the capitalist society, which is reflected in the other people's attitude to them. To restore "normal" relations of temporarily disabled or invalidated people with their social environment, a special rehabilitation system is required.

To some extent, such system is present in every society, being the most developed and diversified in the leading capitalist countries. Thus, it has been recognized that it would be wasteful to lose the working power of physically injured people—and various institutions are trying to enable the invalids to work and to live an active life. This task is becoming much easier due to the development of wide computer networks, as well as automation and computer control of most technological processes. The situation may be quite paradoxical sometimes, when the society chooses to exercise "humanism" and employ the invalids, while many "normal" people cannot find a job and lose their health because of the awful conditions they have to live in.

Former mental patients are a special case. Usually, they have no bodily defects, and their ability to work cannot be doubted. Still, poor knowledge of the origin and functioning of human consciousness makes the behavior of such people less predictable and potentially dangerous for other people and destructive for industrial processes. Most modern conceptions of consciousness assume that it is the property of the individual organism, and particularly the brain; any damage to the brain should then be treated as a disorganization of conscious activity, so that thus injured people could only be employed with a great care, under close observation and with all possible precautions—just to be on the safe side. Naturally, such an attitude is offending the people who have already had an unpleasant experience and are reminded of it every time. This results in additional stress, which may cause a remission of the disease, thus confirming the popular prejudices about the mentally ill.

There are different levels the rehabilitation system may be set up at. Some capitalist states have already adopted the national programs of support for the physically invalidated people, but there are still no such programs for the rehabilitation of the people with deviating psychology. Many "survivor" activists are trying to attract the public attention to this problem creating various organizations and launching movements in support of the former mental patients' right on "normal" life. However, their efforts may lead to the opposite effect, since the very their formation into a separate public force enhances their difference from the "ordinary" people and makes the others to suspect mercenary motives behind the "survivor" activism.

On a wider scale, the problem is to provide the human conditions of life and the access to any activity for the people with behavior deviations. Since nobody can exactly define what is normality, it may be difficult to decide whether a particular type of behavior is socially acceptable or it should be treated as potentially destructive. It is quite easy to classify a genius or a revolutionary as "mad"—and force a psychiatric treatment on them. There is a very dim distinction between "mental illness" and "crime". A highly developed rehabilitation system could help many people to preserve their personality and avoid forced medication. However, no such system can be self-sufficient under capitalism, since it is concerned with the implications only, but never with the cause. In the class society, people will inevitably be divided into opposite social groups, and this fragmentation will penetrate any side of life and activity. Defending the rights of one group is only possible by the expense of the rights (and money) of all the rest of the people, so that the antagonistic nature of the society is reproduced in every kind of relations, at any level.

The richer capitalist states have more resources for the development of the rehabilitation system for invalidated people. However, these resources are not infinite, mainly depending on the ability of the developed countries to rob less developed or weaker nations. As soon as there are no more room to expand, and no more others' wealth to seize, the internal conflicts in the old capitalist countries are bound to break through, and the social programs are first to be sacrificed.

Statistics and Ethics

There may be different approaches to the problem of forced medication and the negative consequences of medical treatment. Thus, one might point out that the discussion of such issues cannot be based on reliable evidence. There are no properly documented data on the particular cases of forced medication, and the statistics of its usage. There is no way to discover which part of thus treated people were injured by the treatment, since the very attribution of the cause of injury is socially biased. The vast literature produced by the "survivor" groups cannot be trusted too much, since it advocates a particular viewpoint and mostly collects the materials supporting it, discarding the circumstances that seem "irrelevant" to the authors. So, there can be no "scientific" talk on the subject, and no way to reconcile the opposite positions, which can only be stated, but never changed. This kind of the categorization belongs to the ethic level of reflection.

Since any statistics is futile where the opposite economic and social interests encounter, the figures are no argument in the polemics for/against forced medication, and no quantitative references may be made. What percent of a person suffers from a medication-induced injury? Is the pain of one person less painful than the pain of the millions? Does in alter the situation if there are just hundreds of injured by ECT rather than thousands of them? Harm and relief cannot be weighed.

The typical quantitative argument is that most patients get much better after the treatment, and it is relatively few who suffer from the side effects or malpractice. Well, this might be convincing if the problem of the efficiency of the current medication techniques were considered. However, the problem of forced treatment is not purely medical, since it concerns the relations between the individual and the society, and not the patient's susceptibility to a specific kind of treatment. Of course, the proportion of side effects should be reduced as much as possible—but the side effects can never be completely eliminated, and the decisions are to be socially motivated anyway. Thus, the efficiency of medication cannot be measured in numbers: one death of the hundred is in no way less distressing than ten or forty deaths, and the only valid criterion is the absence of disease—which is impossible in an unhealthy societal environment.

Another quantitative approach is to stress the existence of much more urgent social problems. Thus, forced ECT is much less frequent than poverty, hunger, oppression etc. Does it mean that the associated problems should not be discussed at all? Yes, they should—though there is a limit of activity above which the ethical evaluations get inverted: if "ECT survivor" activism attracts too much public attention (which is quite possible due to a smell of sensation associated with it), it may mask other acute problems, thus contributing to the process of "pain production" inherent to the current level of economic and social development.

There are two sides in every ethical problem related to forced medication. First, the medicine should help people as it can—and this may assume forced treatment as well. Second, free will of the patients should be esteemed. Doctors have no moral right to reload responsibility to the people in need—but they should not exploit on the patient's vulnerability too much. In ideal, the patient and the doctor should cooperate, and their interaction should be marked with tolerance and compassion, mutual kindness and honesty. Unfortunately, this is not always (if ever) possible in the capitalist society, where compassion and kindness have their market price as anything else. Cooperation with the patient may become dangerous, when the patient is disoriented by noisy advertising or sensation-inflating journalism.

Thus, in a class society, there is a contradiction between the "negative" goal of curing people who do not want it and the "positive" goal of assisting people to feel better. This contradiction is present at any level, from the nation to the individual. The dominant ideology of bourgeois individualism loads the major responsibility for the adequacy of the choice to the individuals, which are virtually never free enough to be responsible for their deeds. So, a doctor has to decide whether to use force for the patient's good, and be blamed for that—or to let the illness grow, and be blamed for that too. Most patients (the poorer ones) have little choice with capitalist medicine. Still, they have to decide whether to fight with those who treat them, or to oppose the social system that cannot guarantee them a healthy life, or at least a decent medical assistance.

There is one more ethical aspect of forced treatment: any coercion is a reduction of humanness in the people. Forced medication may heal the body, or behavior—but it will inevitably cripple a part of personality, poison the consciousness of the former patients. Heavy experiences cripple the souls—though forced medication is just one possibility among many others, since all the relations between the person and the society are based on explicit or implicit coercion under capitalism. For a human being, life is not the highest value, and may be sacrificed for spiritual goals; hence, the spiritual oppression may be much more destructive for personality than physical suffering.

Survivors and Sufferers

The common-level psychology under capitalism is marked by two opposite tendencies. On one side, an individual is urged to be active and to make one's fate with one's own efforts. On the other side, people are being distracted from the fundamental principals of social organization and suggested to pass such thoughts to somebody else, or simply rely on the abstract "order" usually embodied in the state. This internal contradiction makes the people's behavior rather impulsive, which is propagandized by the media as behavioral norm. People make many isolated acts reacting on the alternating everyday situations, but these acts do not constitute any integrity, and the existence seems devoid of any sense, which requires external stimulation to perform anything significant. This is the world of no stable convictions and no preferable direction of development.

As a manifestation of that, any idea has to be pushed forth by private initiative, and appeal to private initiative, competing with many other ideas. However, this forced competition of ideas and projects tends to substitute the goal of economic or social improvement with a quite different goal of winning the prize, whatever it is.

This often occurs to the numerous support groups, which originally unite people who purport to broadcast truth and protect individuals from social pressure, but have to do it in such a sensational and inflated manner, that the original idea gets lost in the flood of extravagant actions and provocative claims. The activists are usually rather copious, and their works are filled with illustrative cases and statistics—both being fiction rather than the results of a serious research. This fiction gradually grows into a tradition, and more recent writings refer to the older products as "authentic documents".

The necessity to attract public attention (that is, to be a strong enough stimulus for the man in the street) makes the activist groups use inadequately aggressive language. Thus, psychiatric "survivors" glow with sacred hatred against psychiatry, speaking in the language of war and presenting every clinical error as a sign of the corruption of the profession in general. Instead of supplying the psychiatrists with a better understanding of their patients, they raise a wave of protest in the professionals; instead of educating the psychiatrists, they try to castrate them. But since any forced medication is a social rather than medical problem, there is no use to blame psychiatrists, without any trouble for those at the power.

Generally, the medicine is blamed for injuring the patients and forcing harmful methods on them and thus making them invalidated and inferior in the eyes of the rest of society. The pity of the ordinary people is a good card to play on. However, the very activity of the "survivors" may become an argument against their movement: the people who feel well enough to lead that active life, to write and publish numerous articles and books, to participate in various disputes and construct personal sites on the Internet—such people do not produce an impression of disability. Few "normal" people can be that robust. The thought is quite logically suggested that all that noise around forced psychiatry is mere disguise, and the actual goals of the "survivor" activism are far from humanism and charity. Anti-psychiatry becomes a means of attaining some economic or political goals.

Activism and Class Struggle

A well-developed capitalist society has a rather complex social organization. There are numerous social groups, layers and classes, and the relations between ethnic formations are built according to the same model: class antagonism. This social hierarchy may unfold itself differently in different respects, and those who belonged to the same social group in one hierarchical structure may belong to opposite (and conflicting) groups in another unfolding. This complexity is far from the old conceptions of class society, with just two main classes struggling for economic and social dominance. Today, class struggle may be hidden under apparent cooperation, it may affect particular aspects of interpersonal relations only, or even be represented by the different sides of the same personality and felt as a subjective experience. This hierarchical complexity reflects the hierarchy of modern capitalist economy, which has developed with the new ways of value production and consumption.

As division of labor is becoming the absolute principle governing the development of capitalism, any kind of activity may, under definite conditions, form into a special business, obeying the laws of capitalist economy. Such transformation is usual for various kinds of social activism, and the wide social movements have certain economic interests behind them, collapsing soon after they have played their role to the end.

Some "survivor" groups are stressing their radical orientation, their negative attitude to the capitalists system and desire to improve the society. They may claim themselves the successors of the old traditions of the working movement, and even flirt with communist ideas. The "survivor" movement is said to struggle against psychiatry as an oppression tool, employed by the ruling class to bring the people to obedience.

Well, there may be some parallels between activism and class struggle. Both are the manifestations of the same antagonistic structure of capitalist society, and there is no impenetrable wall between them. Class struggle may assume the form of social activism, and activism may grow into class struggle. Still, they are different social phenomena, with their own functions within the whole. In a sense, they are complementary — and one can notice that the peak of activism coincides with the low phase of class struggle. This is not a coincidence. The ideology of the working movement is to change the world by a joint effort, so that the particular sides of life would become more bright due to the global change of social organization. The workers are to build the new society by themselves, they are to invent the principles and forms of the future. Quite the opposite of this attitude is represented by the "survivor" ideology of social activism. Its basic idea is the struggle of victims against social evil associated with a limited group of people, the professional "evil-makers". The task of activism is to throw down this social evil, without changing the society itself—the position quite close to bourgeois liberalism. The activists may admit that the roots of the problem are in the nature of capitalism itself—but they cannot imagine how the social system could be changed, and so they have to conclude that all one has to do is to survive. Thus, people are encouraged to be victims, rather than conscious personalities able to change the rules if the rules are against them.

But where can the "victims" get assistance from? Capitalist economy is a self-balanced system, and any shift of the balance in the interests of one social group will result in the redistribution of the public wealth on a large scale. Social activism thus appears to be just another side of economic competition, with every group pulling the blanket onto themselves and quarreling with the other aspirants. Yes, an invalid's participation in the Olympics is a great support for the person's spirit—but the money spent on that might draw a hundred people out of hunger.

The class roots of the working movement and social activism are different too, since activism is almost completely based on the intelligentsia, with its oscillations between angry radicalism and fearful loyalty. The internal contradictions of activism reflect this intermediate social position of the activists. While the working movement may be progressive, activism is merely progressist. Virtually, it often occurs that such progressist movements serve the interests of the wealthier capitalists, being their tool in the economic competition and political struggle. Thus, numerous "green" movements have nothing to do with ecology: their function is to support one group of capitalists against another, to undermine the business of a competing company or the economy of a weaker country. One more example is the noise around forcing psychiatric treatment on political opponents: somehow it finally happens to fight against the communist ideas only, quite ignoring the psychological oppression in the capitalist countries. There is much speculation on the Stalinist regime, and the fantasy of a bourgeois produces enough fiction about the most sadist forms of repression which they readily ascribe to the communists, without a slightest thought of the evidence (which may well be invented afterwards). In particular, Stalin is blamed for the wide use of psychiatry to suppress the political opponents; there is no evidence on that (except the specially invented), and there cannot be any—still, much shouting is enough to make the Philistine tremble.

There is a significant difference between activism and Marxism in that the "survivors" mostly talk about malpractice and potential danger of common procedures, while a Marxist would first investigate the economic and social conditions that has lead to the very necessity of treatment. The activists like talking about human rights—in Marxism, there are no abstract human rights at all, since the relations between people depend on their place in the economy. For Marxist, a capitalist has the right, say, to force medical treatment on a worker who is not obedient enough—but this right is not something "natural" or "inherent" to the class of capitalists, being mere implication of its economical position. The exploited have no rights, and this is their social position too. Of course, this scheme is much less apparent in the developed capitalist societies; however, it can be traced in every particular case, forced medication included.

The corollary of the Marxist approach is that the major cause of any disease is the low level of economic development, with the respectively underdeveloped social organization. Poverty cripples the souls much more often than a "malignant" psychiatrist, and injures the bodies long before they become injured by the "bad" doctors. Ill conditions of life lead to physical illness, while the absence of any hope results in compensatory psychological deviations, readily becoming mental disease. On the other side, the level of medical treatment available depends on the thickness of the purse under capitalism, so that those who need help most often cannot have it at all.

The bourgeois may argue that poverty is not a strong stressor on itself, and poverty does not necessarily lead to mental malfunction or unhappiness. There are so many poor people who are much happier than the rich, who have so many responsibilities and must work hard to preserve their social status. Still, there is no bourgeois who would give all their money to the poor and become as deprived of property and civil rights. The destructive effect of poverty does not depend on whether one had experienced a better life or not—however, individual experience may make a person aware of these effects, thus leading to the conscious frustration and psychological distress. Such people are more likely to be subjected to forced medication for their "anti-social" behavior; this would be a medical procedure, of course, and a kind of healing too—and it is the ill social system that makes them the means of social control. There are no direct implications for class struggle arising from forced medication—rather, the "survivor" activism should serve the needs of a more global social change to become something more than the weep of a hurt puppy.

Seeking for the Future

Social activism (including the "survivor" movements) purports to improve the society, making it more human and protective for its members. Indeed, social changes of this kind could be observed in the developed capitalist countries, and the activists are apt to think that it was the result of their "struggle". They say that activism is to replace the working movement and that it has become the only efficient form of the struggle for a better social organization.

Well, social progress implies some contribution from social activism, though its actual role is much more modest. Class struggle will always remain the major force of development in the capitalist society, and all the achievements of activism could not be possible without a strong support from the working movement (including the international level), which is directly linked to the economic processes. The observable reorganizations of society are due to the drastic changes in economy, and the corresponding adjustment of the basic social relations, in the production sphere.

However, the role of the working movement should not be overestimated too. In fact, the working movement and social activism are the levels of the same hierarchy, and their relations may be inverted in a definite context. They are the complementary sides of the reproduction of the capitalist social organization, and the progress they cause cannot break the very foundations of capitalism, leading to a new socioeconomic formation. Capitalism can be improved, to a certain extent, as long as its internal contradictions can be resolved within the capitalist system. Still, the formation change is inevitable, sooner or later, and the leading force of this change cannot be identified with none of the basic classes of capitalism, and, of course, none of the classes pertaining to the earlier historical stages. Like bourgeoisie was the third force that came to power when the class struggle between landlords and peasants had reached its culmination, there is a new social force in the present society, which will shape the future economic formation to replace capitalism, and this force is different from both bourgeoisie and the working class.

It would be premature to make any guesses until the very economy of capitalism shows the directions where the future of the humanity is to be sought. However, one can say with certainty that the efficiency and progressiveness of both the working movement and social activism depends on whether they support the birth of the new economic formation (and the new social system), thus preparing the conditions for the higher stage of human development to come.