Extremely unbalanced: interest divergence and power disparities between clients and psychiatry.

We have tried to show, first, that there exists a wide divergence between the interests of psychiatry and clients: none of the three major models underpinning society's trust in psychiatrists justify confidence that the interests of psychiatry and its clients converge enough to warrant psychiatrists' speaking and acting for clients in the development of the mental health system and its policies. Second, the distribution of power between psychiatrists and clients is highly unequal: the voices of clients have been co-opted or submerged by those of other groups, particularly organized psychiatry and family-dominated advocacy organizations. Our argument is not based on any particular conception of what the "needs" of clients are--we have not claimed to know what they are, nor, indeed, that they are determinable. However, our point is that the mental health system remains with no good theory to support a proposition that needs will be met, leaving no basis upon which to evaluate the system's success. Therefore, insofar as the "purpose" of this system is to meet client needs, we consider the system to be irrational. The numbers of clients and their presumed intensity of interest in mental health policy should have guaranteed them a place of importance in the political processes shaping the mental health system. There are several structural reasons why this has not been the case: client passivity due to the medical model therapeutic context; hesitancy to engage in public action due to the enduring stigma of mental illness; incapacities caused by psychological distress as well as by iatrogenic dysfunction; organizational weakness due to the free-rider problem of voluntary client groups compared with the ability of psychiatry to encourage contributions to its lobbying efforts; marked client disadvantages in obtaining external funding. If we judge one of the positive features of a liberal democracy to be its stability (in that individuals and groups do not need to resort to violence in order to get a fair allocation of society's goods and costs), we need to be watchful. A political system that systematically disadvantages significant segments of society risks alienating them. While such a situation may (temporarily) benefit a small powerful minority, society as a whole will suffer. Goodwin (1989, p. 47) noted that "over the post-war period the state has consistently sought to recognize greater levels of mental illness in the community."