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National Coalition of Mental Health
Consumer/Survivor Organizations

News

NCMHC/SO Steering Committee member Peter Ashenden testifies before US House of Representatives'

The National Coalition addresses Promoting Wellness on the Individual Level  - September 17-18, 2007

Countering Discrimination and Stigma by Promoting Mental Health Recovery and Resiliency - News Release - May 3, 2007.  Also available in downloadable pdf format (120kb, 2 pages)

National Coalition of People with Psychiatric Histories Responds to Virginia Tech Tragedy - Press Release April 20, 2007

Contemporary American psychiatry has been dealt a shattering blow by no other than one of the most influential psychiatrists in academia - April 18, 2007

DSM and the Death of Phenomenology in America: An Example of Unintended Consequences - April 18, 2007

NCMHCSO Participates in Bazelon Working Breakfast - March 8, 2007

Kennedy-Ramstad Introduce Historic Mental Health Parity Bill - March 7, 2007

The Power of a National Voice: The Coalition Enters a New Era - November 28, 2006

NCMHC/SO Steering Committee member Peter Ashenden testifies before US House of Representatives'

WASHINGTON, DC – March 13, 2008 (Source - USPRA)

Marcie Granahan, CEO of US Psychiatric Rehabilitation Association, Elected Board Member Peter Ashenden and Research Committee Chair Dr. Sandra Resnick testified before the US House of Representatives' Military Construction, Veterans Administration, and Related Agencies (MILCON) and Labor, Health and Human Services, Education, and Related Agencies (LHHS) Sub- committees. Peter Ashenden is Executive Vice President of the Depression Bipolar Support Alliance.

In front of the MILCON Sub-committee, Granahan addressed the lack of funding to provide evidence-based rehabilitative programs to returning veterans, specifically supported employment, and asked that funding be increased for these services through the Department of Veterans Affairs. During the hearing Representative Zach Wamp (R-TN) referred to psychosocial rehabilitation as the "missing link" in veteran's mental health services.

Later that day, Granahan, along with Ashenden, spoke before the Labor HHS sub-committee. Addressing the President's 2009 proposed funding cuts to SAMHSA, particularly to the Programs of Regional and National Significance, both sited examples of the value that the Rehabilitation Research and Training Centers and the Consumer Technical Assistance Centers provide—in addition to the importance of statewide networking grants and state transformation grants—in advancing the recommendations of President Bush's New Freedom Commission on Mental Health and the Institute Of Medicine for self-directed care, recovery, and consumer-centered services.

In an unusual move, Chairman David Obey (D-WI) retreated from the standard passive involvement in hearing testimony and engaged both Ashenden and Granahan with questions and comments. The Chairman went out of his way to remind the committee that last year President Bush's Budget request was $42 million less than the prior year, and the LHHS sub-committee had increased funding to $911 million.

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Promoting Wellness on the Individual Level

Presented at the Substance Abuse Mental Health Services Administration/Center for Mental Health Services

National Wellness Summit to Reduce Co-morbidity and Early Mortality of People with Mental Illness

Rockville, Maryland, September 17-18, 2007

Lauren Spiro, Director of Public Policy, National Coalition of Mental Health Consumer/Survivor Organizations, www.ncmhcso.org

Good morning. I want to thank Paolo del Vecchio and the Center for Mental Health Services for inviting me to speak about promoting wellness on the individual level. My name is Lauren Spiro and I am the Director of Public Policy for the National Coalition of Mental Health Consumer/Survivor Organizations. Our coalition was formed last year. Currently our members include 27 statewide consumer-run organizations and the three national consumer-run technical assistance centers.

I grew up about 20 minutes from here in a middle-class neighborhood. I didn’t have to worry about my next meal or a safe, decent place to live; I took those resources for granted. I don’t take them for granted today; many people who need mental health services and supports don’t have these basic resources.

Like so many of our stories, my story includes abuse, neglect and trauma. By the age of 16, I was in a mental institution. What I most needed was someone to talk with me, to listen to me, love me, respect me, and provide support so I could figure out who I was and find a meaningful place in the community. Instead, the services I received taught me about coercion, force, and control by others, which added layers of trauma and humiliation.

I was diagnosed with chronic schizophrenia. My family was told that I would neither recover nor have a meaningful life in the community; I would spend the rest of my life in mental institutions and I would always need psychiatric drugs.

Fortunately, the experts were wrong. I am the evidence that recovery happens. I have worked very hard to find wellness, and building a strong support network was key. I have had resources, supports, and people who loved me and believed in my ability to heal. I have come a long way from the time I was locked in a seclusion room at the age of 16.

I am not surprised that data show the significant impact trauma plays in the development of mental health problems. I used to blame myself for things that happened to me. I no longer do that. Learning to liberate myself from the damage that was done to me has been the greatest challenge of my life. This process of liberation – learning to be whole and healthy – has given me the greatest rewards I have ever known: love; a sense of meaning, purpose and belonging; and a lot more.

Each individual’s life depends on the society they live in and the services and supports that are available to them. To frame the co-morbidity and early mortality rate as simply a medical issue is not only inaccurate but an injustice to everyone. The problem of co-morbidity and early mortality is an indicator of a broken system within a broken society. The coalition was formed because the survival of our brothers and sisters is being threatened by the oppressive policies, services and attitudes of the system and of society. We die young because we have no hope. We die young because our dreams have been crushed. We die young because our voice is neither heard nor understood. We die young because many of us live in poverty, and some of us live on the streets. We die young because our physical health needs are routinely ignored, often because any problems we have are attributed to our mental illnesses.

To promote my wellness, broad-based systems changes are needed. I need to be a full member of the community and given complete respect for my rights

I need to be in the center of decisions that affect my life. I need people who care for me, respect and believe in me. I need hope, a job, a home and an education. I need to be in charge of my life. I need the same opportunities for life, liberty and the pursuit of happiness that every individual should have. I need an enlightened society that understands that people recover and that every person who comes in contact with a person on their recovery journey can assist in that journey by being hopeful.

In order for my basic needs to be met, the definition of disability needs to focus not on fixing me or adjusting to my deficits but rather on providing services, supports, and treatment designed to assist me to attain or maintain independence and to promote wellness and community integration.

I need health insurance that is independent of my disability status and my employment status.

I need a transformed mental health system that is consumer-driven.

I need consumer/survivors to be proactively engaged in the following five areas: healthcare and mental health planning, policy formulation, training, service delivery, and evaluation.

I need control of my healthcare dollars through self-directed care, which allows public funding to follow the person rather than the provider. This way I can design a personal road to recovery by making decisions to the greatest extent possible with respect to service provision and spending my allotted dollars (e.g., www.flsdc.org, Florida Self-Directed Care). I need personal care assistants, which are also covered under a Medicaid waiver, to help with my basic needs such as getting groceries and living on a budget.

I need changes within the mental health system such as alternatives to hospitalization, peer-run crisis respite (e.g., www.charityadvantage.com/people/RoseHouse.asp), and wraparound community-based services that maintain a client-directed approach.

I need accessible, culturally appropriate, flexible and affordable services that treat me with dignity, respect my rights, and support my self-defined needs. This range of services must include consumer-run and -operated programs, such as peer support, advocacy, self-help, and recovery education services (including Wellness Recovery Action Planning and crisis planning), along with consumer-driven, recovery-oriented professional services. These services and supports help me build internal and external resources and link me to a recovery community. These services need to be available in school mental health programs, programs for older adults with mental health problems, and institutions (such as correctional facilities, nursing homes, and psychiatric hospitals).

I need a safe, affordable, accessible place to live. I need to not be warehoused in institutions, including jails and nursing homes.

I need for everyone involved in my treatment and support to maintain a philosophy of hope that we can heal mind, body and spirit. I need you to believe that I am capable of living the life of my dreams.

I need service providers to understand my experience, including the complex effects of trauma and oppression, before settling too quickly on a diagnosis. A mutual understanding of these dynamics, and the impact they have had on my sense of self, will strengthen our healing relationship.

I need service providers to understand the difference between coercion and alliance and how to share power. Coercion destroys my sense of personhood and identity. Building a collaborative alliance is empowering.

I need education and access to self-initiated, non-pharmaceutical strategies to improve my physical, emotional, and spiritual wellness. These alternative approaches enhance my self-esteem and my sense of meaning, purpose and accomplishment. These approaches (such as yoga, homeopathic medication, vitamins, massage, acupuncture, etc.) need to be affordable.

I need to be in the center of medical decisions that directly impact my life. That means that I respect you, my psychiatrist, as an expert by training: you have knowledge of the scientific literature and clinical experience. And I expect you to respect me as an expert by experience. I know how my body and my mind react in situations or with particular psychiatric medications. I need a relationship built on alliance, not on compliance. I need a collaborative relationship in which we share information and forge a partnership of equals, where we establish consensus on the problem, the goals, and the criteria for success. If I decide that the treatment is worse than the side effects, I need you to work with me to find medications and alternative healing methods that support my unique needs on my journey to wellness.

I need more opportunities for people who have been through the mental health system to train healthcare providers.

I need suicide prevention services, such as consumer-run warm-lines, to enhance peer support, build social networks and reduce crisis center use and hospitalization.

I need to contribute significantly to the community. To reclaim a valued social role, I need meaningful choices that give me the freedom to be in charge of my life.

I need a seat at the table where decisions are made about my life and the lives of my peers. When I speak, I need my voice not only to be heard but to be understood.

I need full disclosure so that I can make informed decisions based on complete and accurate information, so that I understand the consequences of my choices.

I need for my psychiatric advance directive to be honored and respected so that I may determine my treatment based on my values and preferences.

I need integrated, flexible care that is coordinated between mental health and primary healthcare providers, and to have everyone involved, including hospital emergency room staff, adopt a values-based, recovery-oriented approach.

I need diversion programs and prevention programs so that my mental health problems do not become criminal justice problems. When law enforcement does get involved, I need procedures that reduce and/or eliminate re-traumatization (for example, alternative transportation methods, minimizing use of handcuffs and shackles, etc.).

I need school-based, preventive services and supports that focus on building resiliency and wellness before I develop mental health problems.

Someone said that a journey of a thousand miles begins with a single step. Forming the coalition was one step. We need more coalitions at the state and national levels.

Consumer/survivors need to be central in transforming the system. Our voice must be heard. We are the ones dying. We are the ones that have the most at stake in fixing the system.

Lastly, I think the goal of this summit should not be to reduce co-morbidity and early mortality. The goal should be to eliminate it.

Thank you for listening.

References

Deegan, P.E., Drake, R.E., (2006). Shared Decision-Making and Medication Management in the Recovery Process, Psychiatric Services, 57(11), 1636-1639.

Schauer, C., Everett, A., and del Vecchio, P. (2007). Promoting the Values and Practice of Shared Decision-Making in Mental Health Care, Psychiatric Rehabilitation Journal, 31(1), 54-61.

Mental Health Consumer/Survivor Operated Resources

Crisis Respite Programs:

Our Place, 1663 East Main Street, Lancaster, OH 43130, Phone 740-654-0477, email Executive Director: Patricia Waits pawaits@ohiopps.org

Rose House, Orange and Ulster Counties, NY, Phone 845-795-2346, Address 1612 Route 9W, Hilton, NY 12547; Mailing address PO Box 525, Marlboro, NY 12542, http://www.charityadvantage.com/people/RoseHouse.asp

Stepping Stone Peer Support & Crisis Respite Center, 108 Pleasant Street, Claremont, NH. 03743; 603-543-1388, Email stepping_stone@verizon.net, www.Steppingstonenextstep.org

Sweetser Learning & Recovery Center, 174 Mere Point Road, Brunswick, Maine 04011; (207)373-4273; Web site: www.sweetser.worldpath.net//peers.aspx

Youth Movement

Icarus Project, www.theicarusproject.net

Youth MOVE National, www.tapartnership.org/youth/YouthMOVE.asp

Other

Contac - www.contac.org

Sherry Mead Consulting - www.mentalhealthpeers.com

Mary Ellen Copeland, Mental Health Recovery & WRAP - www.mentalhealthrecovery.com

National Mental Health Consumers' Self-Help Clearinghouse - www.mhselfhelp.org – go to Consumer Directed Services Directory (CDS Directory)

Pat Deegan - www.patdeegan.com

National Empowerment Center - www.power2u.org

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News Release - May 3, 2007
Also available in downloadable pdf format (120kb, 2 pages)

Countering Discrimination and Stigma by Promoting Mental Health Recovery and Resiliency

The National Coalition of Mental Health Consumer/Survivor Organizations is a coalition of people with psychiatric diagnoses1 who counter stigma and discrimination through the evidence of their recovery2.

KEY POINTS

  • Research shows that people recover from mental illness/severe emotional distress.
  • People who have psychiatric histories must be included in discussions concerning them just as other groups are included when decisions are made about them.
  • The mental health community needs to focus on wellness promotion and
    programs that support recovery and resiliency.

RECOVERY AND TRAUMA

  • Trauma—such as bullying, physical and sexual abuse, exposure to violence or natural disaster, physical and emotional neglect, and general disrespect of people who appear different or odd—plays a major role in the development of emotional distress and the diagnosis of mental illness.
  • Wellness and recovery services and supports that address trauma are especially needed for young adults because adolescence and young adulthood are stressful, transitional times.
  • Peer-to-peer support and open dialogues with diverse stakeholders are two of the most promising methods of engagement for people with histories of trauma, emotional distress, or mental illness.

MEDIA AND STIGMA/DISCRIMINATION

  • The media perpetuate the myth that people with mental illness are more violent than the general population. Research shows this to be untrue. In fact, people with mental illnesses are more often victims of violence than perpetrators.

  • “Nothing about us without us:” Those of us who have personal experience with recovery from mental illness should be consulted by the media and others when mental health topics are in the public policy arena. We can provide a broader understanding of the issues involved and offer positive solutions. We also can offer information about selfhelp/advocacy organizations we have developed around the country and about the active role we are playing in transforming the mental health system. Allowing others to speak “for” us perpetuates the myth that we are unable to represent our own interests.

INVOLUNTARY TREATMENT VERSUS VOLUNTARY, PEER-DRIVEN SERVICES

  • Involuntary treatment drives people away from mental health services, is stigmatizing and traumatizing, and will not prevent violence.

  • People need an array of voluntary, peer-driven services and supports, as recommended in the
    report of the President’s New Freedom Commission on Mental Health. Such services have a
    proven track record in helping people recover.

RECOMMENDATIONS ADDRESSED TO YOUNG ADULTS, THE MEDIA AND THE ACADEMIC COMMUNITY

  1. Every college campus should offer a wide array of voluntary services and supports, especially peer-run services such as the consumer/survivor movement has created. These would include warm-lines, drop-in centers, stress reduction classes, wellness management, and overnight respite services, which do not carry the stigma and discrimination associated with hospitalization. Consumer/survivor-run statewide groups could offer technical assistance to colleges on developing such services, which should respect the privacy of students who seek them out.

  2. Students should be educated about the traditional and peer-run mental health services and supports available to them on and off campus. Access to services and supports should be flexible and without barriers. This may involve professional or peer counselors reaching out to students who may need support.

  3. School personnel (administrators, teachers, support staff) should be particularly supportive after a tragedy. Voluntary debriefing sessions, listening sessions and informational sessions should be available to help meet the emotional needs of the student community. Peer-run program staff should take part in or lead some of these sessions.

  4. Public education involving college-age youth telling their stories of recovery would provide hope and help counter the stigma and discrimination directed towards people labeled with mental illness. Statewide consumer/survivor groups could mentor students to help them tell their stories

  5. College teachers, administrators, counselors and peer counselors should come together in a dialogue with people diagnosed with mental illness who have recovered, to learn from them about recovery and peer support.

  6. The media and the public need to be informed that people with mental illnesses are no more violent than the general population.

  7. The media need to stop fueling misinformation and myth and revealing private medical information without consent. The media in the United States should follow Scotland’s lead and adopt a standard never to mention a person’s diagnosis in their coverage.

  8. Consumer/survivor activists should work with youth groups such as Active Minds on Campus, The Icarus Project and State of Mine (New Mexico) through participating in Active Minds’ conference in Washington, D.C., in October 2007, to inform youth of the consumer/survivor movement and our experiences with recovery.

  9. Youth groups should participate in Alternatives 2007 (a national conference organized by and for people who have recovered or are recovering from severe emotional distress/mental illness) to inform the consumer/survivor movement of the needs of youth.

1 People with psychiatric histories are also known as consumers and/or survivors.
2 The federal Substance Abuse and Mental Health Services Administration (SAMHSA) has defined mental health recovery as a journey of healing and transformation enabling a person with a mental health problem to live a meaningful life in a community of his or her choice while striving to achieve his or her full potential.

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Press Release - April 20, 2007

National Coalition of People with Psychiatric Histories Responds to Virginia Tech Tragedy

WASHINGTON (4/20/07) – The National Coalition of Mental Health Consumer/Survivor Organizations (www.ncmhcso.org ), an organization of people with psychiatric histories, asks that everyone learn from the tragic events at Virginia Tech, in which a student was responsible for 33 deaths, including his own.

"We offer sincere sympathy to the families and friends of those killed and injured, including the family of Cho Seung Hui, as well as the entire Virginia Tech community," said Lauren Spiro, the Coalition’s director of public policy. “We urge everyone to think compassionately about how to better engage people who are isolated, severely distressed, fearful and/or confused.”

“Let’s turn this crisis into an opportunity to understand more about mental health and create a more healthy and peaceful community,” said Coalition member Can Truong. The Coalition endorses this approach and the importance of supporting one another, and promotes peer-run mental health education, awareness and advocacy organizations such as Active Minds on Campus (www.activemindsoncampus.org).

The Coalition also applauds Mental Health America for urging the public to avoid diagnosing others or engaging in “profiling” of groups such as those who appear to be foreign-born or people with psychiatric diagnoses.

“Reacting with judgment and labeling, fueled by the media, perpetuates misinformation and is a disservice to us all,” said Spiro. According to a study published in the American Journal of Public Health in September 2002, “Violent crimes committed by psychiatric patients become big headlines and reinforce the social stigma and rejection felt by many individuals who suffer from mental illness. But our findings suggest that serious violence is the rare exception among all people with psychiatric disorders. The public perception that people who are mentally ill are typically violent is unfounded.” In fact, research shows that people with psychiatric disabilities are far more likely to be victims than perpetrators of violent crime.

Given what has been reported about Cho’s abuse by bullies, the role of trauma in the tragedy should be understood. “Ninety percent of persons receiving services in public mental health systems have been exposed to trauma,” said Coalition member Mary Blake, a trauma survivor and a consultant to the National Center for Trauma-Informed Care. “Services must be sensitive to the fact of trauma in people’s lives.”

The National Coalition of Mental Health Consumer/Survivor Organizations works to ensure that people who have experienced severe emotional distress have a major voice in the development and implementation of health care, mental health, and social policies at the state and national levels. The Coalition advocates for mental health policies that promote full participation and integration in the community and end discrimination.

“This tragedy is a reminder of the fragility of our humanity and the importance of reaching out with compassion to each other, especially those in distress,” said Spiro.

Contact: Lauren Spiro, NCMHCSO director of public policy, 703-862-6512

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Contemporary American psychiatry has been dealt a shattering blow by no other than one of the most influential psychiatrists in academia.

Vera Hassner Sharav - Alliance for Human Research Protection (AHRP)

Dr. Nancy Andreasen, Director of mental health clinical research at the University of Iowa, the editor of the American Journal of Psychiatry, and author of 500 publications, including the influential book, "The Broken Brain" (1984, recently released) in which she describes the "biological revolution" in psychiatry, has delivered a devastating blow to American psychiatry.

In her critical article in the Schizophrenia Bulletin, Dr. Andreasen makes some astounding acknowledgements--including the fact that American psychiatry is a veritable wasteland in need of "a reverse Marshall plan so that the Europeans can save American science by helping us figure out who really has schizophrenia or what schizophrenia really is..."

Dr. Andreasen points an accusing finger at psychiatry's reliance on an invalidated diagnostic guideline:
 "The DSM has had a dehumanizing impact on the practice of psychiatry. History taking —the central evaluation tool in psychiatry —has frequently been reduced to the use of DSM checklists. DSM discourages clinicians from getting to know the patient as an individual person because of its dryly empirical approach. Third, validity has been sacrificed to achieve reliability. DSM diagnoses have given researchers a common nomenclature —but probably the wrong one. Although creating standardized diagnoses that would facilitate research was a major goal, DSM diagnoses are not useful for research because of their lack of validity."

Yet, she notes, the DSM-III and its successors, DSM III-R and DSM-IV were universally and uncritically accepted as if they were the ultimate authority on psychopathology and diagnosis. DSM forms the basis for psychiatric teaching to both residents and undergraduates throughout most of the United States.

Equally astounding--especially to those who didn't pay heed to critics who pointed out 20th century psychiatry's failings and decades of abusive "treatments"--is that Dr. Andreasen has to go back to the 19th century to find a period during which psychiatry resembled something close to a healing profession:

"the early psychiatrists attempted to develop therapies that might help to relieve mental pain in as humane and effective a manner as possible.

The picture of Pinel freeing the mentally ill from their chains is perhaps the most famous icon of their therapeutic approach. ''Moral therapy'' was developed in many countries in Europe, in Britain, and in the United States. In an era when no pharmacological treatments were available, it emphasized a variety of psychotherapeutic techniques that included personalizing the care to the individual's needs, using non-intrusive and compassionate approaches, appealing to reason when possible, and giving the patient some responsibility for improving symptoms and behavior."

This firm conceptual and moral grounding, she acknowledges, is what psychiatry should strive to maintain--not the invalid, dehumanizing current practices.

She also acknowledges that the evidence has shown since the 1970s that "American psychiatrists were over diagnosing mental illnesses in comparison with the rest of the world and not doing systematic clinical assessments and that their diagnoses and clinical assessments were not reliable."

"Someday, in the 21st century, after the human genome and the human brain have been mapped, someone may need to organize a reverse Marshall plan so that the Europeans can save American science by helping us figure out who really has schizophrenia or what schizophrenia really is..."

In the meantime, psychiatry continues to expand its domain, devaluing those it labels as mental patients, subjecting them to harmful chemical interventions that undermine both their mental and physical health.

Dr. Andreasen is strangely silent about the all-pervasive influence the pharmaceutical industry has wielded on psychiatry during the second half of the 20th century. Conflicts of interest have been a dominant factor in the task force responsible for the formulation of DSM-III R and DSM-IV. Those conflicts of interest have been documented by Dr. Lisa Cosgrove and Dr. Sheldon Krimsky. www.tufts.edu/~skrimsky/PDF/DSM%20COI.PDF and www.ahrp.org/cms/content/view/144/27/ 

ALLIANCE FOR HUMAN RESEARCH PROTECTION (AHRP)
Promoting Openness, Full Disclosure, and Accountability
http://www.ahrp.org and http://ahrp.blogspot.com 
 

Contact: Vera Hassner Sharav
212-595-8974
veracare@ahrp.org

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DSM and the Death of Phenomenology in America:
An Example of Unintended Consequences

Schizophrenia Bulletin vol. 33 no. 1 pp. 108–112, 2007
doi:10.1093/schbul/sbl054
Advance Access publication on December 7, 2006
©The Author 2006. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center.  All rights reserved.   Also available as a PDF - (63 kb, 5 pages)
Nancy C. Andreasen1,2

2The University of Iowa Roy J and Lucille A Carver College of Medicine Mental Health Clinical Research Center, Room W 278 GH, 200 Hawkins Drive, Iowa City, IA 52242

During the 19th century and early 20th century, American psychiatry shared many intellectual traditions and values with Great Britain and Europe. These include principles derived from the Enlightenment concerning the dignity of the individual and the value of careful observation. During the 20th century, however, American psychiatry began to diverge, initially due to a much stronger emphasis on psychoanalytic principles, particularly in comparison with Great Britain. By the 1960s and 1970s, studies such as the US-UK study and the International Pilot Study of Schizophrenia demonstrated that the psychodynamic emphasis had gone too far, leading to diagnostic imprecision and inadequate evaluation of traditional evaluations of signs and symptoms of psychopathology. Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III) was developed in this context, under the leadership of representatives from institutions that had retained the more traditional British- European approaches (eg, Washington University, Iowa).

The goal of DSM-III was to create a comprehensive system for diagnosing and evaluating psychiatric patients that would be more reliable, more valid, and more consistent with international approaches. This goal was realized in many respects, but unfortunately it also had many unintended consequences. Although the original creators realized that DSM represented a ''best effort'' rather than a definitive ''ground truth,'' DSM began to be given total authority in training programs and health care delivery systems.

Since the publication of DSM-III in 1980, there has been a steady decline in the teaching of careful clinical evaluation that is targeted to the individual person's problems and social context and that is enriched by a good general knowledge of psychopathology. Students are taught to memorize DSM rather than to learn complexities from the great psychopathologists of the past. By 2005, the decline has become so severe that it could be referred to as ''the death of phenomenology in the United States."

Key words: DSM/phenomenology/diagnostic criteria/clinical interviews

Introduction

Any dienomenology,'' probably, needs to begin with a definition of what the word ''phenomenology'' means in any particular discussion. This is especially necessary because meanings of words change over time and within different contexts, and phenomenology has been used in a variety of ways that have generated considerable controversy.1 The word phenomenon (plural, phenomena) derives from Greek and refers to outward appearances. It was contrasted with  pathomenon, which referred to underlying meanings that might lie hidden beneath the surface. The term was subsequently adopted by Kant and Hegel, who contrasted phenomena with noumena; the former retained a meaning similar to the original Greek, while the latter referred to higher realities and meanings. However, the meaning of phenomena shifted with latter philosophers. In Heidigger, Husserl, and Jaspers, phenomena were understood in terms of internal subjective experiences. Because Jaspers was an influential and thoughtful psychiatrist, his definition has had considerable impact on the usage of the term. Other articles in this series will no doubt use the term phenomenology in the Jasperian sense.

However, the term phenomenology has also acquired a meaning in contemporary psychiatry that is different from that used by Jaspers and other philosophers and that is more similar to the original Greek meaning. In many writings in contemporary psychiatry, the term refers to the study of psychopathology, broadly defined, including signs, symptoms, and their underlying thoughts and emotions. When used in this way, phenomenology provides the basis for nosology, or the development of disease definitions, diagnostic categories, or dimensional classifications. In this discussion, the term phenomenology is used in this contemporary psychiatric context.

The Origins of Modern Psychiatry: An International Consensus of Shared Values Although this article is about contemporary psychiatry, it is helpful to understand when and how modern psychiatry came into existence because it illustrates the importance of principles and values about which an international consensus was achieved during the eighteenth century. Psychiatry is among the oldest of the medical specialties. It began when individuals trained as general physicians developed a special interest in the treatment of the seriously mentally ill. This became a widespread movement throughout Britain, Europe, and the United States through the leadership of individuals such as Chiarugi, Pinel, Rush, or the Tukes. The movement arose from the crucible of the dawn of modern science and the philosophy of the Enlightenment.

The dawn of modern science provided early psychiatrists with a framework for generating and testing ideas about the nature and mechanisms of mental illness.   Francis Bacon was among the first to articulate the philosophy that would shape the development and methodology of science for the next few hundred years:

Man can act and understand no further than he has observed, either in operation or in contemplation, of the method and order of nature.

Novum Organum2

Pursuing this guidance, people worked out new ways to know (science = to know) about the world through observation, testing, and empirical proof. For example, one of the founders of modern psychiatry, Philippe Pinel, stated:

I, therefore, resolved to adopt that method of investigation which has invariably succeeded in all the departments of natural history, viz. To notice successively every fact, without any other object than that of collecting  materials for future use; and to endeavor, as far as possible, to divest myself of the influence, both of my own prepossessions and the authority of others.

Treatise on Insanity3

Pinel followed those principles faithfully and in the process developed the early principles of epidemiology. He produced case descriptions that are so clear and detailed that his patients can seem to speak in our ears and walk before our eyes. This was phenomenology par excellence, in a prenosological era. As a consequence, the nosology is implicit: the cases are recognizable as classic exemplars of illnesses such as bipolar disorder or paranoid schizophrenia.

The philosophy of the Enlightenment was the second philosophical tradition that shaped the development of modern psychiatry and inspired its early leaders such as Pinel, the Tukes, Rush, or Chiarugi. Its key influence was its emphasis on the dignity of the individual human being and the importance of humanism. There are many famous statements of these principles:

We hold these truths to be self-evident..that all men are created equal..4

Know then thyself, presume not God to scan;

The proper study of mankind is man...5

In this system of being, there is no creature so wonderful in its nature, and which so much deserves our particular attention, as man, who fills up the middle space between the visible and invisible world...6

Guided by these principles, the early psychiatrists attempted to develop therapies that might help to relieve mental pain in as humane and effective a manner as possible. The picture of Pinel freeing the mentally ill from their chains is perhaps the most famous icon of their therapeutic approach. ''Moral therapy'' was developed in many countries in Europe, in Britain, and in the United States. In an era when no pharmacological treatments were available, it emphasized a variety of psychotherapeutic techniques that included personalizing the care to the individual's needs, using nonintrusive and compassionate approaches, appealing to reason when possible, and giving the patient some responsibility for improving symptoms and behavior.

Because the philosophy of the Enlightenment encouraged the conceptualization of human beings—including those suffering from mental illness—as endowed with reason and individual dignity, the psychiatric writings of this era did not tend to dissociate the psyche or mind from the brain. Instead, they were seen as integrated.

For example, the first editor of The American Journal of Psychiatry, Amariah Brigham, stated in 18447:

... the brain is the instrument which the mind uses in this life, to manifest itself, and like all other parts of our bodies, is liable to disease, and when diseased, is often incapable of manifesting harmoniously and perfectly the powers of the mind. It is as if, in some very complicated and delicate instrument, as a watch for instance, some slight alteration of its machinery should disturb, but not stop, its action.

Thus, the gifts of modern science and the philosophy of the Enlightenment to the creation of our specialty of psychiatry included stressing the importance of careful observation in order to understand disease mechanisms and progression, an emphasis on the dignity of the individual, the value of ''moral treatment,'' and the integration of ''mind,'' ''spirit,'' and ''brain'' rather than a dualistic understanding. This has given psychiatry a firm conceptual and moral grounding that it should strive to maintain.

The Rise of Psychoanalysis and the Mid-Atlantic Counterrevolution

The ideas of Sigmund Freud, developed in the early- to mid-20th century, offered an interesting alternative DSM and the Death of Phenomenology in America approach to many psychiatrists, however. They were embraced in many parts of the world and by many individual psychiatrists. The effect was perhaps most striking in the United States. After World War II, psychoanalysis became the dominant conceptual framework in the United States. For a period of 30 –40 years, nearly all the major leaders in American psychiatry embraced psychoanalytic principles and used them to shape psychiatric education and training. This created a new and different zeitgeist. A variety of changes occurred as a result of psychoanalytic dominance.

First, psychoanalysis led to a significant de-emphasis on diagnosis and nosology. As a consequence of work by Kraepelin, Bleuler, and others, a system for diagnosing and classifying psychiatric disorders had been developed in parallel with the development of psychoanalysis and was codified in both the International Classification of Diseases and the Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric Association. In general, the psychoanalytic movement considered diagnosis and classification to be a fruitless endeavor. Defining the nature and source of intrapsychic conflicts was the goal instead.

Second, psychoanalysis, therefore, also led to a significant de-emphasis on careful observation of signs and symptoms—the ''bread and butter'' of the early humanistic psychiatrists and the basis for developing a phenomenology. In fact, the psychoanalysts taught that the patient's self-report of both symptoms and other internal experiences should be discounted. The analyst must dig beneath self-report to reach the real truth. While other countries also had prominent psychoanalysts and psychoanalytic movements, the US acceptance of psychoanalysis was extreme. This distanced most of American psychiatry from Anglo-European traditions and approaches, which continued to teach phenomemology and nosology.

However, a few American institutions maintained ties with Anglo-European psychiatry. The institutions have sometimes been called ''the Mid-Atlantics.'' They included Washington University in St Louis, Johns Hopkins in Baltimore, Iowa Psychiatric Hospital in Iowa City, and New York

Psychiatric Institute in New York City. Despite their small numbers and relative isolation from the rest of American psychiatry, the Mid-Atlantics made some significant contributions to psychiatry during the 1970s. These included the development of the first set of diagnostic criteria,8 the development of the Research Diagnostic Criteria and Schedule for Affective Disorders and Schizophrenia,9 the development of other rating scales for psychopathology —eg, the Thought, Language, and Communication and Affect Rating Scales,10–12 and the highly influential article of Robins and Guze on the validation of psychiatric diagnoses.13

In parallel, significant work was occurring in Europe and especially Great Britain, making the 1970s a time of reappraisal. The Present State Examination provided the international community with a structured interview that could be used to conduct a variety of epidemiological diagnostic studies.14 Foremost among these were the International Pilot Study of Schizophrenia15 and the US-UK study.16,17 The results of these 2 major studies suggested that American psychiatrists were overdiagnosing mental illnesses in comparison with the rest of the world and not doing systematic clinical assessments and that their diagnoses and clinical assessments were not reliable.

Adding to the rising tide of criticism from the Mid- Atlantics was the publication in Science of Being sane in insane places.18 This article reported that 8 sane ''pseudopatients'' were admitted to psychiatric hospitals with minimal to questionable psychiatric complaints (eg, hearing a voice saying ''thud'' on a few occasions); after admission, they denied any symptoms at all, behaved normally, rarely met with staff, and nonetheless remained in the hospital for an average of 19 days and were discharged with a diagnosis of schizophrenia in remission.  Clearly American psychiatry was in a troubled state. It was time for a change. The Mid-Atlantics had their opportunity and began their charge.

The Development of Diagnostic and Statistical Manual of Mental Disorders, Third Edition: Lofty Goals

The changes that seemed to be obviously needed in the principles and practice of American psychiatry were created by the development and publication of a new DSM: Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III). Bob Spitzer, then head of Biometrics at New York Psychiatric Institute, was appointed Chair. He assembled a Task Force comprised primarily of Mid-Atlantics. Their work began in the mid-70s and was culminated by the publication of DSM-III in 1980. At their first meeting, there was universal consensus among the Task Force members that Diagnostic and Statistical Manual of Mental Disorders, Second Edition (DSM-II) should be totally revised.  DSM-III should be evidence based, use diagnostic criteria instead of general descriptions, and strive for maximal reliability. Principles of validity were also considered important, but much less emphasized; the approach was heavily influenced by the article of Robins and Guze on the validation of schizophrenia.13 That article suggested that several different methods could be used to determine if a specific psychiatric disorder could be considered valid: familial aggregation, characteristic  longitudinal course, response to treatment, and laboratory tests (rarely possible).

The Task Force articulated a group of lofty goals that shaped their efforts:

  • To improve communication between clinicians
  • To provide reliable diagnoses that would be useful in research
  • To enhance teaching: to train psychiatry students in clinical interviewing and differential diagnosis
  • To realign American psychiatry with the rest of the world and to be consistent with International Classification of Diseases, Ninth Revision.

To achieve these goals, they made major modifications in the old DSM II.  And extensive text was written for each of the disorders, expanding the length from 38 pages of DSM-II to 295 pages of DSM-III. As the writing evolved, Task Force members began to comment to one another that they were writing a new textbook of psychiatry. This new textbook contained a variety of new principles and innovations:

  • A theoretical about etiology (because for most diagnoses etiology is in fact unknown)
  • Use of diagnostic criteria
  • Dropping of the term ''neurosis''
  • Provision of a glossary to define the terms used in the criteria
  • Multiaxial approach to classification in order to incorporate medical and psychosocial components of a clinical evaluation.

The Task Force members recognized that the increased simplicity and clarity could lead to abuses. Therefore, they filled the introduction with the caveats as follows:

  • The problem of using the manual to set policies:

    The use of this manual for non-clinical purposes, such as determination of legal responsibility, competency or insanity, or justification for third-party payment, must be critically examined in each instance with the   appropriate institutional context.19(p12)

  • The risk that DSM would be taken as the ultimate authority on diagnosis:

    This final version of DSM-III is only one still frame in the ongoing process of attempting to better understand mental disorders.19(p12)

  • The lack of adequate validation for the criteria:

    DSM-III provides specific diagnostic criteria as guides for making each diagnosis since such criteria enhance interjudge reliability. It should be understood, however, that for most of the categories the diagnostic criteria are based on clinical judgment, and have not yet been fully validated by data about such important correlates as clinical course, outcome, family history, and treatment response. Undoubtedly, with further study the criteria for many of the categories will be revised.19(p8)

  • The importance of going beyond DSM criteria in history taking:

    Making a DSM-III diagnosis represents an initial step in a comprehensive evaluation leading to the formulation of a treatment plan. Additional information about the individual being evaluated beyond that required to make a DSM-III diagnosis will invariably be necessary.19(p11)

What Went Wrong? The Unintended Consequences

Although the authors of DSM-III knew that they were creating a small revolution in American psychiatry, they had no idea that it would become a large one and that it would ultimately change the nature and practice of the field. The American Psychiatric Association, which historically had published DSM, was caught completely off guard. Copies sold out immediately, and it took approximately 6 months to catch up with the orders that came flowing in. DSM was purchased by psychiatrists, nurses, social workers, lawyers, psychologists—anyone with any connection to psychiatry.

DSM-III and its successors, Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition and Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, became universally and uncritically accepted as the ultimate authority on psychopathology and diagnosis. DSM forms the basis for psychiatric teaching to both residents and undergraduates throughout most of the United States.

Knowledge of the criteria is the basis for most exams—even the Board Certification examinations taken after residency. As a consequence, classics in psychopathology are now largely ignored.

The ultimate painful paradox: the study of phenomenology and nosology that was so treasured by the Mid-Atlantics who created DSM is no longer seen as important or relevant. Research in  psychopathology is a dying (or dead) enterprise.

How and why did this occur? What is wrong with DSM?

It is not difficult to come up with a list of obvious problems.

First, the criteria include only some characteristic symptoms of a given disorder. They were never intended to provide a comprehensive description. Rather, they were conceived of as ''gatekeepers'' —the minimum symptoms needed to make a diagnosis. Because DSM is often used as a primary textbook or the major diagnostic resource in many clinical and research settings, students typically do not know about other potentially important or interesting signs and symptoms that are not included in DSM. Second, DSM has had a dehumanizing impact on the practice of psychiatry. History taking —the central evaluation tool in psychiatry—has frequently been reduced to the use of DSM checklists.  DSM discourages clinicians from getting to know the patient as an individual person because of its dryly empirical approach. Third, validity has been sacrificed to achieve reliability. DSM diagnoses have given researchers a common nomenclature —but probably the wrong one.  Although creating standardized diagnoses that would facilitate research was a major goal, DSM diagnoses are not useful for research because of their lack of validity.

These concerns led the author to write several editorials for the American Journal of Psychiatry about the current problems that have been created by DSM. Here are a few of Cassandra's complaints:

In the United States an older generation of clinical researchers who led the field for many years have died—Eli Robins, Gerry Klerman, George Winokur. Very few younger investigators are emerging to replace them. The word is out —if you want to succeed as a serious scientist, you need to do something relatively basic. Fortunately, the Europeans still have a proud tradition of clinical research and descriptive psychopathology. Someday, in the 21st century, after the human genome and the human brain have been mapped, someone may need to organize a reverse Marshall plan so that the Europeans can save American science by helping us figure out who really has schizophrenia or what schizophrenia really is.20

We need to make a serious investment in training a new generation of real experts in the science and art of psychopathology. Otherwise, we high-tech scientists may wake up in 10 years and discover that we face a silent spring. Applying technology without the companionship of wise clinicians with specific expertise in psychopathology will be a lonely, sterile, and perhaps fruitless enterprise.21

The creation of an international conference on phenomenology, as summarized in this issue, may help at least a bit to remedy the present situation.

To whom correspondence should be addressed; tel: 319-356-1553, fax: 319-353-8300, e-mail: luann-godlove@uiowa.edu.

References

  1. Andreasen NC. Reply to ''Phenomenology or physicialism?''. Schizophr Bull. 1991;17:187–189.
  2. Bacon F. Novum Organum. London, UK: W. Pickering; 1850.
  3. Pinel P. A Treatise on Insanity. London, UK: Messrs Cadell and Davies, Strand; 1806.
  4. Jefferson T. The Declaration of Independence. 1776.
  5. Pope A, American Imprint Collection (Library of Congress). Essay on man, Epistle II. In: Bredvold LI, McKillap AD, Whitney SL, eds. Eighteenth Century Poetry & Prose. New York, NY: Ronald Press; 1732 –1734:1–2.
  6. Addison J, Steele R. Eighteenth Century Poetry & Prose. New York, NY: Ronald Press; 1939.
  7. Brigham A. Definition of Insanity–nature of the disease. J Insanity. 1844;1:97–116.
  8. Feighner JP, Robins E, Guze SB, Woodruff RA Jr, Winokur G, Munoz R. Diagnostic criteria for use in psychiatric research.  Arch Gen Psychiatry. 1972;26:57–63.
  9. Endicott J, Spitzer RL. A diagnostic interview: the schedule for affective disorders and schizophrenia. Arch Gen Psychiatry. 1978;35:837–844.
  10. Andreasen NC. Affective flattening and the criteria for schizophrenia. Am J Psychiatry. 1979;136:944 –947.
  11. Andreasen NC. Thought, language, and communication disorders. I. Clinical assessment, definition of terms, and evaluation of their reliability. Arch Gen Psychiatry. 1979;36:1315–1321.
  12. Andreasen NC. Thought, language, and communication disorders. II. Diagnostic significance. Arch Gen Psychiatry. 1979;36:1325–1330.
  13. Robins E, Guze SB. Establishment of diagnostic validity in psychiatric illness: its application to schizophrenia. Am J Psychiatry. 1970;126:983–987.
  14. Wing JK. A standard form of psychiatric Present State Examinations (PSE) and a method for standardizing the classification of symptoms. In: Hare EH, Wing JK, eds. Psychiatric Epidemiology. London, UK: Oxford University Press; 1970.
  15. Sartorius N, Shapiro R, Kimura M, Barrett K. WHO international pilot study of schizophrenia. Psychol Med. 1972;2:422 –425.
  16. Kendell RE. Psychiatric diagnosis in Britain and the United States. Br J Psychiatry. 1975;9:453–461.
  17. Kendell RE, Cooper JE, Gourlay AJ, Copeland JR, Sharpe L, Gurland BJ. Diagnostic criteria of American and British psychiatrists. Arch Gen Psychiatry. 1971;25:123–130.
  18. Rosenhan DL. On being sane in insane places. Science. 1973;179:250 –258.
  19. American Psychiatric Association Committee on Nomenclature and Statistics. Diagnostic and Statistical Manual of Mental Disorders (DSM-III). Washington, D.C.: American Psychiatric Association; 1980.
  20. Andreasen NC. Changing concepts of schizophrenia and the ahistorical fallacy. Am J Psychiatry. 1994;151:1405 –1407.
  21. Andreasen NC. What shape are we in? Gender, psychopathology, and the brain. Am J Psychiatry. 1997;154: 1637 –1639.

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NCMHCSO Participates in Bazelon Working Breakfast

By Leah Harris

(Washington, DC) Lauren Spiro, NCMHCSO Director of Public Policy, and Leah Harris, member of the NCMHCSO's DC Advisory Group, attended the Bazelon Center's "Working Breakfast" on March 8, 2007 which featured Congressman Patrick Kennedy and a distinguished panel of key experts on mental health policy initiatives on the Hill. For a detailed summary of the meeting, please visit: http://www.bazelon.org/newsroom/2007/BREAKFAST030807.html.

Spiro and Harris both submitted questions relating to the importance of promoting the consumer/survivor voice in policymaking as well as preserving funding for consumer/survivor and recovery-oriented programs. Panelist Martin Tolchin, Senior Editor and Publisher of The Politico, encouraged consumers/survivors to work together with policymakers to influence the media. He suggested that we need to put pressure on the media to avoid sensationalism and celebrity stories and to put the focus back on real people and real issues. He encouraged us to tell our stories to our policymakers, who can in turn share these stories with their media contacts. We should be reaching out not just to our congresspeople but to their staff as well.

Panelist Connie Garner, Policy Director for Disability and Special Populations for Senator Edward M. Kennedy on the Senate Committee on Health, Education, Labor and Pensions, informed us that "this is the year for mental health issues." She agreed that families and consumers are often on the low end of the totem pole and are not validated by the system. She acknowledged that consumer involvement was essential in the policymaking process. "We need to give people tools to show them that they are part of what's happening," she said. She supported the creation of ombudsman programs with agencies like the Department of Labor and Health and Human Services so that the consumer voice could be more systematically incorporated into policy. She noted that consumers and stakeholders also need to have more active roles in the evaluation of SAMSHA state performance plans.

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KENNEDY-RAMSTAD INTRODUCE HISTORIC MENTAL HEALTH PARITY BILL

Large Bipartisan Majority Support

March 7, 2007

Contacts: Robin Costello 401-729-5600 (Kennedy)
Dean Peterson 202-225-2871 (Ramstad)

WASHINGTON DC -  Congressmen Patrick J. Kennedy (D-RI) and Jim Ramstad (R-MN) today introduced "The Paul Wellstone Mental Health and Addiction Equity Act "( H.R. 1367), to improve the overall health of all Americans by granting greater access to mental health and addiction treatment and prohibiting health insurers from placing discriminatory restrictions on treatment.

Since February, the Congressmen have been crisscrossing the country touting the merits of the legislation with their "Campaign to Insure Mental Health and Addiction Equity". The response has been overwhelming with support surfacing from every corner of society. The legislation is cosponsored by an historic bipartisan majority of 256 Members of Congress, including House Leaders.

"This bill is really very simple," said Congressman Kennedy. "Millions of Americans pay their premiums every month, but when they or their children or family members get sick, their insurance isn't there for them. That's not fair and it's not smart. This is a public health crisis that in some way touches every family in America. It's time to break down the barriers to good mental health and addiction treatment."

"It's time to finish what we started in 1994 with our friend and colleague, the late Senator Paul Wellstone, and end the discrimination against people with addiction," said Congressman Ramstad "This is not just another public policy issue. This is a life-or-death issue for millions of Americans."

The bill expands the Mental Health Parity Act of 1996 by requiring group health plans that offer benefits for mental health and addiction to do so on the same terms as care for other diseases. The legislation closes the loopholes that allow plans to charge higher co-payments, coinsurance, deductibles, and maximum out-of-pocket limits and impose lower day and visit limits on mental health and addiction care.

According to the Government Accountability Office, nearly 90 percent of plans impose such financial limitations and treatment restrictions on mental health and addiction care despite voluminous scientific research documenting the biological, genetic, and chemical nature of these diseases, and the effectiveness of treatment. Both the House and Senate version of the bill applies to group health plans of 50 or more people.

Last month, The Senate Health, Education, Labor and Pensions Committee approved similar legislation, The Mental Health Parity Act of 2007, sponsored by Senators Kennedy (D-MA), Domenici (R-NM), and Enzi (R-WY). Among the differences is that the House bill, informed by the sponsors' forums across the country, requires health plans offering mental health benefits to cover the same mental health and addiction disorders that are included in the health plans Members of Congress use. The Senate bill has no such provision. The bills also differ in how they impact related state laws.

The Kennedy-Ramstad legislation is modeled after the Federal Employees Health Benefit Program, which covers Members of Congress and other federal workers and dependents and which implemented equality in mental health and addiction coverage in 2001. According to an exhaustive study published earlier this year by the Department of Health and Human Services, the federal employees' parity policy was implemented with "little or no increase in total MH/SA [mental health/substance abuse] spending".

A majority of respondents to a National Mental Health Association survey indicated that they would support parity legislation even if it meant a $1 per month increase to their premiums. The Congressional Budget Office has estimated that such legislation will increase health care costs less than that amount.

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The Power of a National Voice: The Coalition Enters a New Era

On November 28, 2006, the collective voice of the mental health consumer/survivor movement was heard on Capitol Hill for the first time. On that day, two representatives of the National Coalition of Mental Health Consumer/Survivor Organizations had hour-long meetings with aides to Senator Edward Kennedy (Health and Human Services Authorization), Senator Tom Harkin (chair of the subcommittee on Labor, Health and Human Services, Appropriations) and Congressman Patrick Kennedy (House lead on mental health).

“November 28 was a historic day for our movement,” said Coalition director of public policy Lauren Spiro, who, with Steering Committee member Dan Fisher, met with the Senate and Congressional aides. “In the past, it has been difficult to get 10 minutes of one aide’s time on Capitol Hill. But now there is a new era of political power for mental health consumer/survivors. On November 28, our collective voice was heard on Capitol Hill as never before – although I do not want to detract from the efforts of individual consumer/survivor leaders who have had an impact on the Hill.”

One such leader applauded the new initiative. “As an individual who has been trying to hold down the fort,” said Steering Committee member Joseph Rogers, “I really welcome the new, more collective organizing effort that the Coalition represents. While we have been able to have an impact on legislation, it has been piecemeal. My hope is that, with the Coalition, we can have a more consistent presence in Washington, resulting in our collective voice truly being heard.”

Senator Kennedy’s aide told Spiro and Fisher that she found the Coalition’s values statement a good starting point, and invited Spiro to participate in a Substance Abuse and Mental Health Services Administration re-authorization group she is putting together to develop principles, policies and proposed legislation. Senator Harkin’s aide requested a follow-up meeting with the Coalition, tentatively scheduled for January 11, 2007. “Harkin’s aide said she would involve more staff interested in mental health,” Spiro said. Congressman Kennedy’s legislative aide is interested in working with the Coalition to pass parity legislation, Spiro added. “It is clear that having a coalition is giving us access we never had before.” Coalition Steering Committee member Kathy Muscari said she would try to schedule a January 11 meeting with the office of Senator Robert Byrd (Senate Appropriations Committee).

“After our meetings on November 28, Dan and I had a clear sense that our voice was heard and that we are now at the table,” Spiro said.

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