Madness without State: practices of Mutual Support and Community Activism in Mental Health of the Organization “Autogestión Libre-mente”

This text approaches the invention of other ways of well-being and care around needs not covered by the mental health system. Through an ethnographic approach, the practices of community activism and mutual support of the collective “Autogestión Libre-mente” are studied, a group from Santiago de Chile that holds weekly meetings under the principles of voluntary association and peer support. The values of horizontality and reciprocity as axes of shared work imply a strong political content and a “therapeutic” sense, without the latter being the explicit purpose of the activities they organize. Around this experience we reflect on the implications of the assembly methodology and deliberative democracy in the configuration of new forms of mental health from the community in the contemporary scenario.


Introduction
The predominance of the biomedical model, the expansion of medicalization, and the excessive use of psychiatric coercion are elements that shape contemporary mental health and are an object of discussion at a global level 1 . In response to this, the promotion of recovery-oriented community mental health services based on human rights has been emphasized, including the importance of social support and nonpharmacological alternatives 2 . Similarly, social participation and community inclusion has been highlighted, emphasizing the benefits that people find in establishing relationships linked to informal support 3,4 .
In this context, community organizations for the defense of rights and the exercise of citizenship have acquired a central character. In this regard, the scope of social and political participation of people with lived experience in mental health has been described, including the exercise of the right to freedom of conscience, freedom of expression and freedom of association, favoring the development of new forms of noninstitutional participation 5 . One of the most relevant aspects of these initiatives refers to the modalities of self-help and mutual support provided by peer groups, including a depathologizing approach to human diversity, the independence of mental health services and the ability to function without psychiatric help [6][7][8][9] .
In Chile, the community approach promoted by the State has not implied a process of closing psychiatric hospitals. Biomedical practices have been integrated into community networks, strengthening an authoritarian and vertical model, with a pharmacological predominance in care processes 10 . Along with this, promotional and preventive aspects linked to citizen participation are not prioritized in mental health services. Thus, the institutional framework has not achieved to integrate the potentialities, strengths and resources of the community 11 .
Historically, local and community-based groups made up of people with lived experience in mental health have questioned institutional frameworks, organizing among themselves to give each other what the psychiatric system is not capable of delivering. In accordance with this tradition, in Chile, citizen initiatives have begun to develop that challenge the advances, setbacks, and challenges of the community model, reinventing the traditional forms of political expression and social participation in mental health 12 .
Under these guidelines, this article makes a brief tour of the instances of citizen self-organization and associative experiences in the field of mental health that have been developed since the 1960s, to then investigate, from an ethnographic approach, the practices of mutual support and community activism of the collective "Autogestión Libre-mente". This organization was born in Santiago, Chile as a space for collaboration and meeting between people related to the field of mental health to share resources, coordinate actions and support each other. This study is proposed with the purpose of exploring the scope of participatory instances that could help achieve therapeutic effects without being direct and proper therapies 13 , as well as mobilizing new imaginaries around community care and collective well-being in contemporary society.
In first-person: citizen self-organization and associative experiences in mental health Throughout the 1960s and 1970s, various liberation struggles against the established powers began to gain prominence in the public sphere. In the United States, the black movement for civil rights and against racial segregation, feminist self-awareness groups, sexual diversity organizations, and the Independent Living Movement in the field of disability reported innovative processes of collective empowerment and political participation 14 . In this context, initiatives to promote freedom from the coercion of the psychiatric system also arise along with demands for social justice. This is how the movement of ex-patients or survivors of psychiatry was born, dedicated to providing information on rights in mental health facilities, campaigning against abusive practices in psychiatry, promoting legal reforms at the local level and developing services directed by users 15 .
In various cities in the United States, Canada and England, associative experiences of users and ex-users are developed to share their experiences in the mental health system and deploy resistance actions against psychiatric oppression [16][17][18] . Specifically, in the early 1970s, various groups led by survivors of psychiatry emerged in the United States, who organized meetings and demonstrations to promote changes in the mental health system. Among the most relevant ones, it is worth mentioning the Insane Liberation Front that was born in 1970 in Portland, the Mental Patients' Liberation Front in Boston and the Mental Patients' Liberation Project in New York in 1971, as well as the creation of the Madness Network News newspaper in San Francisco in 1972. On the other side of the Atlantic, the Mental Patients Union formed in London in 1973 stems from the idea that people who have received psychiatric diagnoses needed a union to fight against political repression and social control of psychiatry.
Thus, organizations and local support networks initiated protest actions and mobilization of legal resources for the defense of rights, based on the denunciation of practices such as electroshock, involuntary hospitalizations and forced psychiatric treatment, emphasizing that former patients or survivors of psychiatry could speak with their own voice and represent their interests 19,20 . Along with that, this movement developed informal support networks centered on the principles of mutual aid and exchange among equals to address shared needs, in tune with the actions that were part of the liberation movements of the time 21 .
In this regard, in the field of sexual diversity, organizations dedicated to providing spaces of refuge and support for queer youth in situation of social exclusion emerge 22 . In the field of functional diversity, Independent Living Centers are developed, directed and controlled by people with disabilities in order to provide peer support and care, which is the origin of the figure of personal assistance for community life 23 . Along the same lines, the movement of ex-patients or survivors of psychiatry began to implement community systems of mutual support, favoring the construction of self-defense and support networks among peers.
Specifically, the so-called user-directed services 24 originate when users and ex-users of the psychiatric system come together to overcome stigma and isolation, share their problems, talk about their unmet needs and reflect on the type of help that is really useful to them. In this way, initiatives arise aimed at providing continued emotional support, access to education, residential alternatives and ways out of the mental health system, evidencing its failures and contradictions. One of the most relevant was the Mental Patients Association (MPA) in Vancouver, Canada, which involved the creation of social centers based on voluntary work and mutual support 25 . Similarly, in the United Kingdom, the informal network of activists "People Not Psychiatry" emerged, an organization that developed an experiment in community life and mutual aid supported by its members in a recovered house 26 .
Consequently, the movement of ex-patients or survivors of psychiatry emphasized the importance of developing consciousness-raising processes favoring the creation of communities sustained by mutual aid. One of the basic principles of these initiatives referred to understanding that people who have received psychiatric diagnoses are capable of helping themselves and each other. Therefore, in self-managed centers they can see themselves from a different role to that assigned in the mental health system, to the extent that their experiences are understood as normal reactions to the stresses of real life, they can talk about the meaning of these experiences with their peers and share coping strategies under a peer support model 25 . In the same way, in accordance with the voluntary nature of mutual support, members are free to get involved with the degree of contact and participation that they choose, helping to promote autonomy and self-determination in the modalities of aid 25 .
For Chamberlin 21 , one of the characteristics of mutual support groups was the exclusion of people without lived experience, forming separatist spaces in order to avoid the influence and cooptation of mental health professionals. In turn, these initiatives implied the development of relationships and bonds to promote quality of life and recover citizenship rights, allowing people who have received psychiatric diagnoses to regain effective control of the decisions that affect their own lives. On the other hand, Chamberlin 25 argued that consciousness-raising processes were not a form of therapy insofar as mutual support spaces allowed for questioning biomedical narratives and the expertise of health officials.
Ultimately, the movement of former patients or survivors of psychiatry moved from the formation of groups to share experiences of abuse and violence in the mental health system, as well as marginalization and stigma in the social scenario, towards the creation of alternative services led by people with lived experience, to give each other what the psychiatric system was not capable of delivering. That was the origin of the modalities of community support to resist and challenge psychiatric authority, turning personal experience into political action.
The scope of this movement remains relevant globally, expressing the importance of first-person voice in the field of mental health 27 . In this regard, the formation of mutual support groups currently shows that associative practices and solidarity networks constitute a relevant force in contemporary mental health 28 .

Methodology
This research is carried out under a qualitative approach, a perspective that explores the way in which people construct the world around them and the meanings they give it, safeguarding the particularities of social contexts 29 . In turn, from an ethnographic approach, it is proposed to produce information on the social interactions that occur among the actors of a community 30 . According to Graeber 31 when conducting an ethnography, "you observe what people do, trying to extract the symbolic, moral or pragmatic logic that underlies their actions, you try to find the meaning of the habits and actions of a group" (p. 24).
The methodological proposal adheres to a committed ethnographic research to the extent that the process of participant observation is conducted from a position of collaborator of the community group studied. In this way, an attitude of listening and involvement in their daily activities is developed, favoring processes of constant (self) reflection on the meanings present in social life. In this regard, it is proposed to "observe those who are creating viable alternatives, try to anticipate what may be the enormous implications of what is-already -being done, and return those ideas not as prescriptions, but as contributions, possibilities, as gifts" 31 (p. 24).
The field as an area in which subjects interact, meanings are shared and multiple social and symbolic practices are made explicit 32 corresponds to the meetings of the collective "Autogestión Libre-mente" held between 2016 and 2018. These meetings were held once a week in the premises of a bookstore and social center located in the civic center of the city of Santiago. The meetings were attended by people with lived experience in mental health, professionals who consider themselves allies of the mad movement, university students studying social sciences and health-related fields, mental health workers, family members and friends of users of mental health services as well as any interested person as it constituted a free and open space for the community, without access barriers. With an average attendance of 15 people (men and women, adults, from different sectors of the city in its territorial and socioeconomic diversity), the meetings would last three hours.
Based on the deployment of participant observation and ethnographic records from relevant activities and events, the data analysis strategy corresponds to a systematization and classification of the material with the purpose of developing a thematic writing and conceptual relationships that allow reconstructing the collective experience 32 . Regarding ethical aspects, the informed consent of the group was requested to develop the study and present the results of the research, in order to promote the formation of first-person organizations in the field of mental health.
According to the orientations indicated, the practices of mutual support and community activism in mental health that the collective "Autogestión Libre-mente" has developed are described below.
Practices of mutual support and community activism of the collective "Autogestión Libre-mente" In this section, the analytical matrices of the information obtained in the field work are presented based on a narrative exposition of the forms of participation that characterize the collective "Autogestión Libre-mente".

Voluntary association and horizontal relations
At the beginning of each meeting, what is called "miscellany" is developed, which is a free conversation before deciding who is going to facilitate the meeting. An established practice is that a person with lived experience volunteers, or can be proposed by the attendees, to carry out the tasks of compiling the topics to be addressed in the meeting, taking note of the turns to speak and moderating the conversation. This represents a rotation exercise in group facilitation tasks. Any attendee can propose topics to be discussed at the meeting, which are written down on a whiteboard and remain in a visible place. In general terms, when people attend for the first time, the first item on the agenda is called "introductions" and refers to those present to voluntarily introduce themselves and share the reasons for their participation in the space. The other points on the whiteboard are varied and in each meeting refer to emerging issues that arise from the attendees. At the end of the session, the people who attended for the first time are voluntarily asked to express what they thought of the meeting and how they felt in the space.
The "Autogestión Libre-mente" collective has not defined rules for internal functioning or norms that regulate collaborative work for the development of meetings. However, there are concrete and shared ethical guidelines that are perceived. In this regard, the custom of not interrupting the person speaking, attentive listening, and safeguarding speaking turns that promote a respectful environment predominates. Another important aspect refers to the fact that there are no prohibited topics to address in the group conversation, all opinions are allowed and attendance at the meetings is free and voluntary, therefore, anyone can leave the space, even without giving explanations, as well as how to come back whenever you want. In turn, it is common during meetings to share tea, coffee and cookies that are located on a table in the center of the room so that each person can help themselves. These resources are collected from donations from attendees. Another custom is the collection of a fee of 500 pesos, which is charged at the beginning or at the end of the meeting by a person in charge of keeping the money and keeping the accounts. This cooperation is voluntary and the resources are invested in supplies and materials for the collective's actions (printing posters, purchase of canvases, paints and brushes, among others).
One relevant aspect regarding the absence of formal rules is that there are no membership criteria in the organization and no one is in charge of the space, in the sense that anyone who attends the meetings can feel part of the collective. On one occasion, one of the most active participants in the group put the invitation to attend a radio program as a point on the agenda to share the group's work. In this regard, a person with lived experience who was attending the meeting for the first time offered to go to the radio station, which was accepted by the attendees. The foregoing reflects that the collective "Autogestión Libre-mente" is not a traditional formal organization where incorporation requirements are defined and a board of directors is elected. On the contrary, it is a space in which there are no hierarchical structures or different statuses among the members of the group, which allows to value the commitment and motivation of the people who attend the meetings, on equal terms, as spokespersons of the collective.

Unity in diversity and search for consensus
Within the framework of the diversity of participants in the collective "Autogestión Libre-mente", the right to dissent and openly discuss is safeguarded, to the extent that people feel free to express what they think. A display of the plurality of visions that converge in the space refers to the meeting of people who are in favor of the use of psychiatric drugs and people who do not promote their use. The following scene illustrates the coexistence of conflicting opinions on this point in the group space: in a meeting there was applause for a person who commented that he had stopped consuming psychotropic drugs after a discontinuation process that had begun months ago and immediately afterwards, a person gave psychiatric medication to another member who had requested it, as they had run out of it. In this way, in the collective "Autogestión Libre-mente" people who take psychotropic drugs are not excluded, however, their intake is not naturalized, the importance of discontinuation is shared and freedom and autonomy are promoted in meetings of people regarding pharmacological treatment, valuing and safeguarding the personal decision of each member regarding this matter.
As an instance of reflexivity among peers, the issues raised are addressed from the recognition of alternative paths, safeguarding pluralism and diversity of perspectives. This promotes the construction of a climate of trust to share intimate experiences, socialize knowledge and undertake joint actions. In this community framework, the prominence of people with lived experience is safeguarded, avoiding that people who have not had this experience appropriate the space or the use of language with interventions based on theoretical currents such as antipsychiatry.
Another important aspect of the collective "Autogestión Libre-mente" refers to the ability to mediate differences, the openness to not deny conflicts and accept them as part of the group space. The previously described is reflected in the fact that the people who attend the meetings participate in equal conditions in decision-making processes. In general terms, decision-making by consensus predominates, to the extent that processes of mutual agreement and synthesis are favored to reach agreements. Although necessary time is reserved for debate and seeking common grounds, discussions are not too lengthy, their closure is not postponed, and the process is not terminated. Along with this, consensual mechanisms integrate the right to dissent. On more than one occasion, it is observed that if a proposal or invitation directed to the group is not collectively supported, in all cases the possibility of participating on a personal basis is recognized, therefore, individual participation is not restricted. In turn, majority voting is not used to decide on any aspect discussed in the meetings.
Thus, despite the conflicting visions on some issues, the search for consensus predominates as a process of synthesis in diversity and the recognition of individual autonomy in the face of collective decisions.

Bonds of reciprocity and de-professionalization of mental health
During the meetings of the collective "Autogestión Libre-mente" two thematic fields are addressed in the group conversation. On the one hand, personal experiences are shared around madness, psychiatrization, diagnoses and treatments in the mental health system, as well as the forms of abuse and violence that are expressed in care environments. On the other hand, political actions are proposed to be developed by the collective, such as the organization of protest days against electroshock 33 and the Mad Pride marches 5 , among other activities that are carried out annually. Thus, the people who attend share their experiences and are reciprocated in the same terms by other members of the group. This meeting space allows people to speak, configuring other ways of being together, deploying community activism practices to face these shared problems.
Regarding the first thematic field, the collective meetings constitute a space for free expression of emotions to share fears and concerns without being judged. For this purpose, the person who takes the floor can speak at length without time restrictions, receiving questions from the people who attend that allow them to delve into what has been proposed, while safeguarding the right not to respond if the person does not wish to do so. In this way, a collaborative and empathetic environment is developed among peers, focused on the recognition of coping strategies and the shared understanding of resources to modify situations perceived as unfair. Thus, meetings allow sustaining senses of belonging and affective bonding based on company and mutuality. "What cannot be done alone, can be done in a group," says Rodrigo, a participant of the collective.
However, the scope and implications of mutual support have been discussed within the collective. On one occasion, a participant with lived experience mentioned the importance that a person who is going through some emotional difficulty between meeting periods could receive support from the group. In this regard, it was proposed to activate a "protocol" of action with the formation of a duo "psychologist-mad person" to meet the needs presented by the person. This proposal generated a debate on the priority of having a professional to address subjective crisis situations. It was also questioned why there should be people "in charge" of dealing with such situations, to the extent that any member who has needed support has requested it directly with those who have a greater affinity and closeness, therefore, standardized help roles should not be established. In this way, a "mad protocol" was proposed as an alternative, which refers to the idea that people who are available to help express their willingness to do so, and people who need support can reach out to them if they so choose. In this process, the professionals who attended the space did not offer to assume these roles, safeguarding the importance of peer support.
The above mentioned has significant components. Firstly, the emotional difficulties that participants in the meetings may present are assumed as a collective problem that can be addressed under conditions of horizontality. Secondly, relationships of reciprocity are established insofar as the people who receive support can also provide it when needed, and vice versa. Third, the proposed debate made it possible to assess the importance of relationships between equals, breaking hierarchical care structures based on professional support. Finally, support needs and aid modalities were addressed without delegation of power, promoting the responsibility and involvement of all participants, also recognizing the involvement of people with lived experience to make themselves available to people who may need care. This exercise contributes to the fact that people are not perceived at all times as recipients of help, but also as facilitators.
In this way, peer support is assumed collectively, based on relationships of solidarity, safeguarding genuine concern and mutual care.

Engaged activism and community mobilization
An aspect related to concrete organizational tools refers to a style or way of resolving the issues discussed in meetings that participants define as "A lo libre-menteee" providing a place for humor and creativity. This reflects a mechanism for addressing the issues discussed with openness to flexibility, without fixed ideas or immovable postulates based on the recognition that each situation is resolved spontaneously and situated, involving pragmatism and originality. The examples of this way of doing things are multiple and varied, however, it is worth mentioning a practice that was developed for a few weeks as a support strategy for a colleague who was going through financial problems. The above consisted of organizing a solidarity raffle with the aim of raising funds. This festive way of giving monetary support made it possible to get out of the logic of charity and paternalistic relationships, adding a playful element to this form of cooperation during the meetings.
Finally, in the collective "Autogestión Libre-mente", expressions of mutual support are not separated or distant from social activism and political action in the public sphere. On the contrary, the meetings address the preparation of workshops, debates or talks, as well as the organization of demonstrations, marches and rallies. Thus, the weekly meeting spaces are constituted as an assembly instance to share points of view and make decisions regarding the initiatives of the mad movement. The way in which these issues are addressed is relevant, since the discussion of the issues, the development of the proposals and the lines of work that are defined, are interconnected with the modes of mutual support that the collective develops.
In particular, the frequency of the meetings allows the personal processes that are shared in the space not to be postponed in preference for the proposed tasks and actions. Rather, the uniqueness of each person is embraced to enhance collective work, with each individual contributing what is possible within their emotional situation. This way, the importance that each member has the same possibilities of action and contribution is safeguarded, however, it is also acknowledged that each person has their own pace and it is legitimized that each one can contribute to activism from their own place. Therefore, to the extent that the meetings are informative and resolutive, personal and collective rhythms are conjugated, favoring coherence and continuity between political action, peer support and self-care. "Libre-mente is the best therapy, without being a therapy", says Carlos, one of its members.

Final considerations
The collective "Autogestión Libre-mente" develops practices of mutual support and community activism in mental health with particular features in contemporary Chile. Although this initiative is not constituted as a separatist and exclusive space, as described in the peer support tradition of the ex-patient or survivor of psychiatry movement, its own dynamics are established where the leading role in first-person activities is favored in the collective The meetings held by the group are characterized by the diversity of their participants and the plurality of the topics that are addressed, however, in this heterogeneity common values are observed: horizontality, mutual aid, voluntary association, community self-management, rejection of professional hierarchy, decisionmaking by consensus, reciprocity and solidarity. The configuration of these elements condenses into more complete forms of participation in which roles are equal and interchangeable: when some people always lead, horizontality is lost, therefore, the rotation of tasks limits the consolidation of roles of power. On the other hand, when you give in at all times, without discussion, there is no assembly work, therefore, mediation and consensus-building are at the center of collective action. Thus, people with lived experience who participate in "Autogestión Libre-mente" can move from a position of passivity and dependency in mental health services, towards a space of emotional support where the ability to help among peers and the recognition of their collective action as experts by experience.
In this way, "Autogestión Libre-mente" represents an initiative in which other modes of care and well-being predominate to generate support and act politically in the field of mental health. At this point, it differs from other self-help groups that are born within or at the borders of the health system, to the extent that the group develops independently from the tutelage, impulse, or sponsorship of the institutional framework. In turn, the deliberative democratic mode in which decisions are discussed and elaborated in meetings, as well as the reception and listening among peers, shows that these tasks have not been delegated to the State.
In this sense, the practices of the collective "Autogestión Libre-mente" allows us to rethink a community mental health model beyond interventions and forms of assistance focused on the specialized work of technicians and professionals. Specifically, this experience implies questioning the attempts of institutions to monopolize functions related to the production of mental health, to understand that health services should come after what the community can and wants to do 34 . In this regard, in a context of social isolation and forced dependence on hostile systems, mutual support becomes a radical act 35 .
On the other hand, the development of demonstrations and protest actions against the abuses of psychiatry is one of the expressions in which community activism can be "therapeutic". This figure allows us to appreciate the affective and relational dimension in the exercise of militancy. Indeed, these instances of collective support contribute to an assessment of interdependence and care among peers in political processes.
Lastly, the experience of the collective "Autogestión Libre-mente" emphasizes the importance of rebuilding the social fabric and reconnecting people in reciprocal relationships based on their abilities, not on their deficits 36 . In this way, the actions of this group are in line with an understanding of social movements aimed at creating spaces of freedom, participation, and joint management of social affairs 37 . And in broad terms, the organization addressed is part of the melting pot of Latin American experiences that are based on the creation and production of new types of social relations, non-capitalist, based on self-government, self-determination and community coexistence [38][39][40] .
While the initiative studied is oriented towards the constitution of local micro-orders, it allows for an approach to everyday practices that are frequently overshadowed by institutional intervention. In this regard, the scope of this study refers to a written account of what was experienced and happened after a prolonged presence in the field, however, it is proposed to delve into the narratives of the participating subjectivities, involving them in future research and writing processes around this experience. However, these expressions of autonomy in the field of mental health allow us to move towards creative forms of organization and different worlds, beyond the capitalist system and the State structure, in contemporary society.