PETER CAMPBELL

I want to begin by saying something about the direction of this piece - who it is coming from and who it is principally addressed to. System survivors are the key words here. This piece is not coming from someone who defines himself as a service user and it is not directed primarily at those who define themselves that way.

What I am suggesting is that there may be real differences between those who call themselves "system survivors" and those who choose to describe themselves as "service users" - although these differences may not always be clear. Fashion may play a part in the choice. People are not necessarily making a clear statement through self-definition. But often they are.

And on the face of it there are differences. Use and survival are not the same. For one thing use is neutral about the experience and survival clearly is not. Anne Plumb, a survivor, has written:

I agree with Anne Plumb.

But there is also a difference between a service and a system so that there appear to be doubts about the true location of the problem. For me, services are part of a wider system. The difficulties I face are due not just to services but to social attitudes and practices, to our inheritance of the history of madness. I am caught up in a mental health system more complex and deep-rooted than services alone. As a result of this type of analysis I believe that system survivors are often more radical in their demands and are looking for much more than improved services.

And, while looking at self-definition, it is worth asking whether there are possibly real differences between people who call themselves "psychiatric or psychiatric system survivors" and "mental health system survivors". Speaking as one of the latter, I may be placing a different emphasis on the role of psychiatry in the difficulties we face. Perhaps these sort of differences will be relevant to the remaining parts of this piece.

Questions of what we should be doing and what we can actually do are obviously linked. I want to deal first with the importance of agendas (the itemisation of what we are going to do and why) and control of agendas for service user/survivor action. I believe not having such agendas or having adequate control over the available agendas, particularly the more radical agendas, has been a major problem in the past.

One aspect of the problem is that we have lost control of agendas through working with other groups who are more powerful than us, are more organised and have more urgent agendas than ours. There are underlying difficulties in being involved in work that is wrapped up in the seductive notions of common concerns or partnerships when we are the conspiciously less powerful partner, when others are always issuing the invitations and we are always the new arrivals at the party. Survivors are always likely to have a weaker hold on agendas and we have not helped ourselves by being shy about refusing to enter dodgy partnerships unless the deal was re-negotiated.

But loss of control has been made more likely by our reluctance to have coherent, clear and well-communicated agendas of our own. In the early 1980s groups like the Campaign Against Psychiatric Oppression (CAPO) and British Network for Alternatives to Psychiatry (BNAP) had written manifestoes. While not necessarily arguing for a return to those, how easy is it for any of us to respond clearly to a question about what the service user/survivor movement really stands for? We could strengthen our position measurably if we sharpened up the focus of our actions.

So, if clear agendas are vital then deciding if reducing the biomedical dominance of psychiatry should be near the top of the survivor agenda becomes important. Who or what is the "real enemy"? And here questions of what we want to change and what we are best placed to change start to intermingle. I am not going to spell out here what I think the survivor position should be, but rather put a number of questions that I feel survivors should be asking ourselves and each other about our positions:

• Is biomedical psychiatry a prime target or is the predicament of system survivors more about the dominance of professionals across a number of professions?
• If our situation is linked to multi-facetted abuse of power, what particular contribution does the biomedical approach make to worsening the abuse? If it is about misuse of power, wouldn't it serve us better to frame it in that way rather than in terms of the advance or retreat of particular psychiatric approaches?
• And what about social control? The social control functions of public psychiatry have been on and off the survivor activists' menu in recent years although it has always been recognised as one of the central ingredients. Belief in the social control function of services was an entry pass into the action groups of the early 1980s. The government's emphasis on compliance in the community has put social control back in the spotlight recently. But how does social control and biomedical psychiatry interrelate?Where does discrimination and the predicament of women and ethnic groups fit in?

Moreover, accompanying these questions, and foreshadowed in some separatist approaches, is the dilemma: Is psychiatry - biomedical or otherwise - capable of change? Can we ever transform mental health services? In an era of the Disability Discrimination Act, the Human Rights Act and mental health promotion to the public, should we be looking elsewhere than the old entrenched interest groups and make alliances on a broader platform of social change with other oppressed groups?

Do we need to confront biomedical psychiatry at all?

These are some of the issues that survivors need to be deciding for ourselves at the same time as considering what we actually can do. In terms of practical action, my strong feeling is:

• That we must begin by developing our own agenda and our analysis into something much more coherent. This would not be difficult to achieve if it was given a high enough priority.
• We should be realistic both about what we can achieve and what system survivors' most effective actions are likely to be - how can we best contribute to the changes we want. I feel the history of the last twenty years does tell us something useful about what survivors are best and most successful at doing.
• We need to be realistic that some service users will be issuing different messages and fighting different battles to ours. We should confront the suffocating blanket of representativeness and legitimacy and assert that our cause is worth considering even if 51% or more of our peers do not agree with us.
• We need to be aware that radical action has achieved relatively little so far. Clinical authority remains secure, the use of drug treatments and ECT has not been effectively challenged.

In the face of these realities, survivors must make what they do real and relevant to "ordinary people", including service users/survivors who are not activists. There is a danger that a struggle with biomedical psychiatry could, like the "is there such a thing as schizophrenia?" debate of the 1980s, spiral off into the stratosphere, seemingly irrelevant to the day to day lives of people with a mental illness diagnosis.

And finally, and crucially, survivors must look at how we work together and who we work with. After 20 years, I am still unsure of how well system survivors really work with each other. I certainly feel we could do much better. If we are to address the struggle against biomedical psychiatry, we will only make progress if we look up from our other actions and make time and space to come together for discussion. Perhaps we should also be looking for alliances with disabled people, many of whom share our opposition to the medical model.

If we accept that alliances will be necessary, we need also to consider whether and how we work with radical mental health workers. In the mid-1980s collaboration within groups did occur only to be succeeded by the ideal of service user/survivor only groups. Now the possibility of working within the same groupings as well as in alliances between groups seems to have re-emerged.

My feeling is that survivors need to get their act together on their own even if seeking collaboration and alliances at the same time. I believe that professionals' tendency to dominate will occur unless survivors are sure of their ground. Once we are sure and have decided what we want to do and how we want to work, we must seek to work with others, including mental health workers. Indeed I don't see how we could resist the biomedical dominance of psychiatry otherwise. But for me, imbalance of power remains the fly in the ointment in all respects. And unless we can set up the parameters for working together and control and even make the invitations, I would be looking for alliances not partnerships.

I am actually in favour of survivors taking action against biomedical psychiatry but not unless that action is well-considered and directed. There are dangers in gathering around a flag that someone else has planted, just because it flies quite proudly and has colours similar to ours. But if we have doubts, the answer is not to stand colour-less but to raise our own flag with our own true colours and fight on alongside The current initiative on biomedical psychiatry deserves a survivor-response and in the course of it, perhaps a second flag.

Plumb, A., 1993. The Challenge of Self advocacy. Feminism and Psychology 3:169