Mental Health

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50 Signs of Mental IllnessA Beautiful MindA Beautiful MindA Bright Red ScreamA Casebook of Ethical Challenges in NeuropsychologyA Corner Of The UniverseA Lethal InheritanceA Mood ApartA Research Agenda for DSM-VA Slant of SunA War of NervesAbnormal Psychology in ContextADD-Friendly Ways to Organize Your LifeAddiction Recovery ToolsAdvance Directives in Mental HealthAggression and Antisocial Behavior in Children and AdolescentsAl-JununAlmost a PsychopathAlterations of ConsciousnessAm I Okay?American ManiaAmerican Psychiatric Publishing Textbook of Neuropsychiatry and Clinical NeurosciencesAn American ObsessionAngelheadAnger, Madness, and the DaimonicAnthology of a Crazy LadyApproaching NeverlandAs Nature Made HimAsylumAttention-Deficit Hyperactivity DisorderAttention-Deficit/Hyperactivity DisorderBeing Mentally Ill: A Sociological Theory Betrayal TraumaBetrayed as BoysBetter Than ProzacBetter Than WellBeyond AppearanceBeyond ReasonBinge No MoreBiological UnhappinessBipolar 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WorkHow People ChangeHow to Become a SchizophrenicHow We Think About DementiaHughes' Outline of Modern PsychiatryHumanizing MadnessHysterical MenHystoriesI Hate You-Don't Leave MeI Never Promised You a Rose GardenI Thought I Could FlyI'm CrazyImagining RobertImpulse Control DisordersIn Others' EyesIn Two MindsInsanityIntegrated Behavioral Health CareIntegrative MedicineIntegrative Mental Health CareIntuitionJust CheckingKarl JaspersKissing DoorknobsKundalini Yoga Meditation for Complex Psychiatric DisordersLaw and the BrainLaw, Liberty, and PsychiatryLegal and Ethical Aspects of HealthcareLiberatory PsychiatryLife at the BottomLife at the Texas State Lunatic Asylum, 1857-1997Life Is Not a Game of PerfectLithium for MedeaLiving Outside Mental IllnessLiving with AnxietyLiving With SchizophreniaLiving with SchizophreniaLiving Without Depression and Manic DepressionLost in the MirrorLove's ExecutionerLoving Someone With Bipolar DisorderMad in AmericaMad TravelersMad, Bad and 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Related Topics
On Our Own, TogetherReview - On Our Own, Together
Peer Programs For People With Mental Illness
by Sally Clay (Editor)
Vanderbilt University Press, 2005
Review by Aleksandar Dimitrijevic
Nov 7th 2006 (Volume 10, Issue 45)

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.


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