The psychiatric consumer movement has two distinct segments. One is dominated by relatives of persons diagnosed as mentally ill. It has made major contributions to funding research on schizophrenia and depression and advancing financial parity for psychiatric care.

The other segment of the consumer movement is composed of people who have been known to psychiatrists only as patients. The more militant designate themselves as "survivors," regarding their contacts with organized psychiatry as more stressful than their presumed disorder; some have embraced elements of the antipsychiatry movement. Others, acknowledging a relationship with psychiatric services, prefer to call themselves "users." Both reject the designation of "consumer" as it implies a nonexistent equality of power with professionals and a freedom of choice (as in the marketplace) that they do not always have.

The major goals of those who constitute this movement are the achievement of greater self-determination, freedom from institutional restraints (including compulsory hospitalization and treatment), and the development of user-controlled treatment facilities. Their transformation from an aggregate of isolated individuals, represented largely by conventional mental health associations in which they did not participate, into a self-aware collectivity began after World War II, a period when other minority populations were beginning to realize their own potential power.

Initially the former patients provided support for each other as peers who experienced similar difficulties. Over time some of their encounters became institutionalized in a range of settings—each other’s homes, drop-in centers, or small businesses.

In many parts of the world these take the form of clubs with participants called members rather than patients. The clubs (for example, Fountain House in New York City) represent a compromise between total autonomy and total dependency on professionals. They may hire at least one full-time staff member, typically a social worker, and offer vocational training, job placement, and sleeping quarters, as well as social support.

This compromise is not, however, acceptable to everyone. Many feel that authentic self-help services must be totally directed and run by users/survivors. In such settings, the overriding values are choice and autonomy in contrast to professionally directed services where symptom removal has paramount value. It is of particular concern to users/survivors that symptom removal is regarded by many professionals as justification for coerced treatment.

One response to this concern was the U.S. "mental patients’ liberation movement." As documented by survivor Judi Chamberlin, it started in the early 1970s with a major goal of "developing self-help alternatives to medically based psychiatric treatment and securing full citizenship for people labeled ‘mentally ill.’" A number of organizations have been formed to pursue these goals. In the era of the Internet they have multiplied with Web sites and interactive networks. Their sentiment is expressed in the title of one Web site’s essay, "If It Isn’t Voluntary, It Isn’t Treatment."

Since 1982 the World Federation for Mental Health (WFMH) has tried to facilitate a new pattern of relationships between user/survivor groups and the mental health establishment at the international level. This required enhanced sensitivity to the dignity and self-esteem of those who had felt marginalized by society and excluded from full participation in decisions affecting their lives.

The WFMH invited these groups to participate in its regional and world conferences and, largely through grants from the NIMH, was able to support the travel of many. In 1989 it assisted in the formation of a World Federation of Mental Health Users (WFMHU) and in 1993 elected that group’s president, Mary O’Hagen of New Zealand, as the first user/survivor member of the WFMH board of directors.

However, some user/survivor groups began to feel they were losing the militancy that led to early successes. Among them was the world’s oldest national organization of users/survivors, the Association for Social and Mental Health, which was founded in Sweden in 1966 and now has 10,000 members in 26 regional divisions. Although its governing board once included professionals, its members regarded it as "too smooth and adjusted to authorities." Today all of its elected officers are users or ex-users of psychiatric services.

In the Netherlands, Jan Dirk van Abshoven, leader of the European Network of Users and Ex-Users in Mental Health, formed between 1991 and 1993, enunciated a clear philosophical difference from mental health professionals, conceiving of mental health as a human right rather than a health issue: "Absolute health does not exist. . . .[T]he person’s individual dignity outweighs. . .health."

This perspective bears on the strongly held views against neuroleptic medications held by many users/survivors.

Despite variations, however, the move toward collaboration between professionals and users/survivors continues. Several university-based psychiatry departments are pioneering the use of former patients as staff members, especially in outreach programs. There is a growing realization that the most effective way to reduce stigma is to collaborate on a peer basis with ex-patients in meaningful work.

The movement is beginning to reach beyond the industrial democracies to foster users’ movements in the Eastern Mediterranean, South America, and Eastern Europe.

Over the long run, recognition of organized users/survivors and their participation in developing and supervising treatment programs may be among the century’s more significant advances in psychiatric care.