The world of mental health is replete with models. Professionals think about their work in one set of terms or another, ranging from biological through psychological to social, each bringing its own assumptions, attitudes and priorities. We invest much energy in developing models, elaborating them and, most importantly, arguing that one is better than another. Yet one of the most robust findings from user-led research is that professional models are without great significance. From the user's point of view, what matters most are questions of dignity, engagement, trust and regaining hope. These are more associated with the values and attributes of individual practitioners and teams rather than the models they use.

The central argument of post psychiatry is that we need to move beyond the modernist technical frameworks and models of 20th-century psychiatry if we are to keep faith with the growing user movement. This movement - radical, articulate and confident - promises a major cultural shift in the way that we as individuals (and as a society) experience states of madness, distress and alienation. The French philosopher Michel Foucault spoke about the history of psychiatry as a 'monologue' of reason about 'unreason'. For the first time ever, the rise of the user movement offers the possibility of real dialogue. But to engage in this, professionals will have to 'think outside' their models and work towards a more inclusive agenda.

In this article {the first of six), we shall link post psychiatry with the idea of citizenship. Post psychiatry is not another model! We believe that if we can see mental health work in terms of the promotion of citizenship rather than curing model-defined problems, we can begin to move beyond the divisive agendas of the past.

The word 'citizen' refers to someone who is allowed, and is able, to participate fully in the society of which he/she is a member; someone who benefits from the rights and carries the responsibilities available to other members of that society. Citizens only forfeit certain rights if they contravene the laws of their society. But for us, there is more to its meaning. Our analysis is closer to that of the writer Michael Ignatieff: 'Citizenship has its active modes (running for political office, voting, political organizing) and its passive modes (entitlement to rights and welfare).¹

He makes the point that both these modes of citizenship go together and cannot be separated. Citizenship is about much more than holding a passport or being on the electoral role of a particular country. Being a citizen is about being regarded as a full human being, entitled to expect the same from life and the society in which one finds oneself as everyone else. On a basic (passive) level, it involves being free from discrimination, exclusion and oppression. On a more positive (active) note, it means being able to define one's own identity and to celebrate this identity in different ways.

Not being a full citizen means that you have a 'life less worthy' than others. The implications of this are extremely serious, and no list of the effects of loss of citizenship will ever be complete. Liz Sayce² provides an excellent overview, summarised below:

• Loss of life: The Nazis sent inmates of mental hospitals to the gas chambers, with other 'non-citizens' such as Jewish people, gypsies, homosexuals and political dissidents

• Violence: Read and Baker's³ survey of 778 service users found that 47 per cent had been physically attacked

• Restricted parenting rights: This ranges from eugenic programmes of forced sterilisation through to unwarranted questioning of parenting skills

• Restricted migration: A history of 'mental disorder' can debar an individual from entry to the USA

• Social exclusion and discrimination: Huxley and Thornicroft⁴ note that in Britain the employment level of psychiatric patients rarely reaches 10 per cent

• Poor physical health care: Medical personnel sometimes do not take service users' medical problems seriously. Consequently, the diagnosis of cancer and other serious illnesses may be delayed⁵

• Complaints to criminal justice system: These are frequently not taken seriously if the person complaining is known to have a mental health problem. For example, rape has not been uncommon in psychiatric hospitals, yet few prosecutions have resulted

• Exclusion from society: One study found that two out of three service providers {both statutory and non- statutory) had experienced NIMBY [not in my back yard] opposition to planned service changes between 1992 and 1997.⁶

Service users often maintain that discrimination and exclusion are their greatest problems, more serious and difficult for them than the issues that brought them to psychiatry in the first place. The citizenship agenda in mental health places these issues centre stage. As full citizens, service users are entitled to the best medical drugs available, well-resourced support services and clear information about treatment risks and benefits. They are also entitled to jobs, decent housing, proper physical health care and freedom from discrimination. This side of the citizenship agenda is well understood by users and professionals, and there are already well-established campaigns against stigma and discrimination.

The service user movement is a broad church. Some groups (for example, the Manic Depression Fellowship and Rethink), are content to define their problems through the models of psychiatry. However, an increasing number of individuals and groups are refusing to use the language of professionals. Organisations like Mad Pride, Mad Women, The Hearing Voices Network and the recently launched Paranoia Network seek new ways of describing themselves. They reject professional models and therapy, and identify with other human rights campaigns; for example, the struggle for gay rights, which is primarily concerned with creating spaces in which gay people can define and celebrate their own identities.

Active citizenship presents the greatest challenge to professionals. It requires an ability to set aside models, diagnostic categories and therapeutic techniques, and a concerted effort to get alongside individual service users and groups in their attempts to define their struggles in a different idiom. In fact, it requires the ability to engage critically with one's own professional background. This does not entail abandoning our professional training, but it does highlight the need to redefine the relationship between professions such as medicine and the struggles of those who endure states of madness, distress and alienation.

We suspect that many of our colleagues in psychiatry will have the greatest difficulty with this aspect of citizenship. As doctors, we are taught to encounter phenomena such as voices, self-harm, sadness, suicidal feelings and paranoia as psychopathology - symptoms of disease processes. Our 'diagnose and treat' medical model is an easy fix. Our diagnoses explain quickly; our drugs deaden immediately. But increasingly, service users tell us that this approach robs their experiences of meaning and strips them from the lived contexts (social, cultural, personal) in which they have arisen. This has many effects. Perhaps most important of all is the loss of belief in the value of oneself as a person that many service users experience at the hands of medical psychiatry. Once a person starts to think of their thoughts, emotions and behaviours as 'diseased', this conclusion is never far off. In other words, our argument is that our models (especially the medical model) are part of the problem when it comes to users overcoming the idea that they have a 'life less worthy'. Our frameworks and interventions can undermine citizenship every bit as much as the discrimination of employers or the hurtful comments of neighbours.

Signing up to a citizenship agenda with its active and passive dimensions will be a real challenge for many professionals. However, we propose it as something positive, something inclusive. We believe that many professionals recognise the need to change the way they think about mental health and to redefine their relationships with service users. The citizenship agenda recognises the importance of better treatments and services. It supports campaigns against discrimination and stigma. But it also works to bind these to increasing demands from user groups for spaces in which some fundamental assumptions about mental health can be questioned.

1. M.Ignatieff (1989) 'Citizenship and moral narcissism', The Political Quarterly, 60: 63-74.

2. L. Sayce (2000) From Psychiatric Patient to Citizen: Overcoming Discrimination and Social Exclusion, London: Macmillan.

3. J. Read and S. Baker (1996) Not Just Sticks and Stones: A Survey of the Stigma, Taboos and Discrimination Experienced by People with Mental Health Problems, London: Mind.

4. P. Huxley and G. Thornicroft (2003) 'Social inclusion, social quality and mental illness', British Journal of Psychiatry, 182: 289-90.

5. L. Sayce and L. Measey (1999) 'Strategies to reduce social exclusion for people with mental health problems', Psychiatric Bulletin, 23(2): 65-7.

6. J. Repper, L. Sayce, S. Strong, J. Willmot and M. Haines (1997) Tall Stories from the Back Yard: A Survey of Nimby Opposition to Community Mental Health Facilities Experienced by Key Service Providers in England and Wales, London: Mind.