One aspect of Sally Clay’s
experience is, most unfortunately, far from unique. For instance, in the
concluding chapter she writes: "I was one of those patients, serving out
my time in an involuntary commitment. I had been there about three weeks and it
was almost time for me to be sent home; I was still in the down phase of my
last manic episode, brought further down by the heavy doze of Thorazine I was
given […] I had spoken to the psychiatrist only once since I arrived at AMHI.
The day after my admission he talked to me for less than ten minutes and
prescribed the anti-psychotic medication without ever returning to see how it
affected my thinking and mood" (p. 239). 

I am sure that many people around
the globe have been subjected to this same process. What, however, is unique in
Clay’s case, is that she did not write a memoir. On Our Own, Together is not an
autobiography of a former psychiatric patient but a review of a new approach to
mental health and a scientific study of its effectiveness. For Clay goes on to
say: "I had been hospitalized over a dozen times at this point, but this
time I had learned from some of my fellow patients at AMHI that there was a new
organization in Portland for families, and that former mental patients were
joining" (ibid.).

Through this organization, and
dozens of similar programs across the US, former mental patients have tried to
achieve several goals. If I were to make a list of these goals, I would give
first rank to overcoming "passive dependency that they had to cultivate in
order to negotiate the mental health system" (p. 242). Out of this goal
springs articulation of their critique of and anger at the traditional medical
model. From their personal experience, they write that the "mental health
system tends to objectify and coerce" (p. xii) and talk about "a
legacy of abuse, dehumanization, and coercion that was found in traditional
mental health service systems" (p. 19). This is labeled mentalism — in
analogy with racism and sexism — and is claimed to have grave consequences:
"Recovery from the consequences of treatment are often more difficult than
recovery from the illness itself" (p. 43). The third, and maybe the most
important, goal was that they formulate their own alternative position. It
started with realization of the importance of peer relations: "As
consumers shared their life stories, they realized that their psychiatric
problems were not a result of personal deficits but were instead indicators of
society’s systematic oppression supported by the practices of the mental health
system" (pp. 34-36). It influenced their vision of a favorable therapeutic
relationship and alliance in terms of the provider’s caring functions and
concern. Finally, it caused changes in matters practical, since they believed
that most of their problems were practical ones: "where to live, how to
get a job, or how to obtain welfare" (p. 38).

By their basic purpose, all these
programs founded across the US in order to provide former mental health system
consumers with social support and assistance with issues of everyday living can
be divided into three categories:

1.                 
Drop-in centers: they provide varied services, such as meals and housing
assistance for members, as well as a place to meet friends and relax in a
stigma-free environment;

2.                 
Peer support and mentoring: these emphasize one-on-one relationships
which provide peer support within the larger community;

3.                 
Education and advocacy: here mental health consumers attend classes in
order to learn recovery skills for themselves or advocacy for themselves and
other consumers.

Description of selected programs
from each of these groups makes the larger part of this volume. Still, rather
than retelling it, I shall review what makes the book unique: a presentation of
the first ever major quantitative study of self-help mental health programs.
Namely, the book reports on a four year federal study of peer-run programs
named "The Consumer Operated Services Program" (COSP). It was
performed on various sites, in eight different states, in order "to examine
successful programs run entirely by mental health consumers for their peers […]
their operation and expenditure controlled exclusively by
consumers/survivors" (p. 3).

In the beginning phase, the
research question was whether there were any common ingredients in all the
programs. Consumers and researchers worked together and defined 26 common
ingredients organized into five categories:

1.                 
Program Structure: the administration and primary activities of these
programs are independent of provider organizations and consumers control its
board of directors, staff, and budget;

2.                 
Peer Support: denotes that individual participants are available to each
other to listen with empathy and compassion based on common experience:

3.                 
Environment: this category includes safety (meaning: "a noncoercive
milieu that soothes fears resulting from past trauma, including trauma induced
by mental health system" — p. 10), informal setting, accessibility, and
reasonable accommodation;

4.                 
Education/Advocacy: the core ingredients of this category are
self-management and problem-solving strategies, and self-advocacy; it also
includes system advocacy, and community education.

5.                 
Belief Systems: its core ingredients are the peer principle, where peer
is defined as someone with similar experiences and challenges; the helper’s
principle, which means acting for the benefit of both oneself and others and in
a friendly rather than professional manner; and empowerment, defined as a sense
of personal strength and efficacy, with self-direction and control over one’s
life; this category also comprises creativity and humor, choice, recovery,
acceptance and respect for diversity, and spiritual growth.

The book provides a useful review
of preconditions and purposes of good fidelity studies (p. 216ff.), but it is
more important that it reveals sound empirical data. Using the above mentioned
five categories, researchers created Fidelity Assessment Common Ingredients
Tool (FACIT), which was administered to a large number of consumers. It
includes six domains based on the categories of core ingredients, which were
operationalized. The questionnaire’s psychometric features are excellent:
reliability is acceptable at the item level and high at the total score level.
And the results are suggesting that the programs are very important and deserve
every attention and support: One shows that "there is a notable
variability among the three clusters of COPSs" (p. 233), but a more
important among the primary findings says that "COSPs and Traditional
Mental Health Services display measurably different patterns in their
expression of these ingredients, with COSPs expressing them to a much greater
degree" (p. 236).

Though these results are very
inspiring, the study closes with a strikingly frank exposition of the limitations
of its findings: "One question that still needs to be addressed is whether
the common ingredients of consumer-operated services are actually active
ingredients. That is, do the kinds of things that differentiate
consumer-operated and traditional services actually lead to differences at an
individual level […] The relationship between performance by the program on the
FACIT and by individual outcomes of any type has not yet been established"
(p. 237). It seems beyond any doubt that this relationship will be established
soon. The enthusiasm of participants, organizers and researchers, together with
importance of this novel approach to mental health, will certainly provoke many
others to join the field and to continue with research.

In conclusion, I would strongly
recommend this book to various categories of readers and for various reasons:
it offers critique of traditional psychiatry that should be familiar to many
who were a part of that world one way or the other; it reviews a revolutionary
approach to mental health system that everyone involved in helping professions
should be aware of; it provides empirical data that confirm validity of
theoretical models and call for further research. Let us hope for more
contributions from this camp.

 

© 2006 Aleksandar Dimitrijevic

 

Aleksandar Dimitrijevic, Faculty of
Philosophy, Department of Psychology, Belgrade, Yugoslavia.

Categories: MentalHealth