ALTERNATIVES TO PACT FOR WASHINGTON STATE

FEBRUARY 28, 2006

BY

Carole Willey

Clifford Thurston

Steven Pearce

The Fundamental Problem

The fundamental problem with the current mental health system is that virtually no one recovers their health and very few are even making progress toward recovery. [Reference King County RSN Recovery Model report for 2001, 2002 and 2003 less than 1% recover their health. This King County ordinance is or rather was (it was modified and no longer tracks recovery of health) unique in the state of Washington. No other RSN, nor the MHD tracks recovery of health]

The public mental health system can be deemed to be a system of maintaining individuals in their chronic mental illness. [Reference: CCHR White Paper on CREATING CHRONIC ILLNESS, August 2004]

This places a tremendous burden on the public mental health system to meet existing demand, yet still be required to service anyone new to the system who is Medicaid eligible.

MENTAL HEALTH SYSTEM REFORM

There are several “reform” efforts underway. The Mental Health Task Force spawned HB 1290 and SB 5763. We also now have the Mental Health Transformation Grant with it’s subcommittees meeting around the state currently.

One of the issues being pushed are “Evidence Based Practices”.

PACT appears to be being pushed, because it is being called an Evidence Based Practice.

WHAT IS PACT?

PACT stands for Program of Assertive Community Treatment. Notice the word assertive. One of the main goals is ensuring treatment compliance.

A PACT team can include: generalist staff trained as registered nurses, clinical psychologists, case managers, substance abuse specialists, occupational therapists, and vocational specialists, in addition to part-time psychiatrists.

P/ACT [PACT is known by other names, i.e. without the P as ACT) was originally developed as an alternative to psychiatric hospitalization, with the goal of allowing people to live independently in the community. But, in reality, P/ACT has evolved into a coercive, lifelong and non-client*-directed system with medication compliance as its most basic tenet.

PACT IS NOT A RECOVERY PROGRAM

PACT does not solve the system-wide problem that people are not recovering their health – their dependence is being maintained.

According to the analysis of PACT in Clark County the mean GAF score is 54.3 which is in the “moderate” category. The range of this score appears to be 41.2 to 67.4. This means individuals symptoms range from serious to moderate – but nevertheless in the dependent to less dependent category – not recovered.

HOW TO GAUGE RECOVERY
THE ORIGINAL KING COUNTY RSN ORDINANCE ON RECOVERY

For the years 2001 through 2003 King County RSN reported annually on outcomes based largely upon GAF (Global Assessment of Functioning) scores. Clients were rated as:

Recovered above 81

Less Dependent 51 to 81 – mild to moderate symptoms or

Dependent less than 51 – serious symptoms

GAF scores are part of Medicaid eligibility requirements in Washington State. They are a widely accepted measure of mental health. You can see this scale on the following pages.

Global Assessment of Functioning (GAF) Scale

Superior functioning in a wide range of activities, life’s problems never seem to get out of hand, is sought out by others because of his or her many positive qualities. No symptoms.

Absent or minimal symptoms (e.g., mild anxiety before an exam), good functioning in all areas, interested and involved in a wide range of activities, socially effective, generally satisfied with life, no more than everyday problems or concerns (e.g., an occasional argument with family members).

If symptoms are present, they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument); no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork).

Some mild symptoms (e.g., depressed mood and mild insomnia) OR some difficulty in social, occupational or school functioning (e.g., occasional truancy or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships.

Moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) OR moderate difficulty in social, occupational or school functioning (e.g., few friends, conflicts with peers or co-workers).

Cont on next slide (slide 5)

GAF SCALE – CONT.

THE NEW MHD STRATEGY HAS A GOAL TO FOSTER AUTONOMY

Chapter 4 ● Transformation Goals, Objectives, Strategies and Performance Measures

B. IMPROVE CONSUMER SELF-SUFFICIENCY – PUBLIC VALUE

Goal 2: Mental health care is consumer and caregiver driven, with consumers, families, caregivers and advocates involved in individual recovery and resiliency process.

Develop and implement concepts and programs that prioritize goals and outcomes that foster autonomy rather than maintenance and codependency.

Strategic Plan 2006-2011 Mental Health Division

RECOVERY OF HEALTH IS POSSIBLE

DR. DANIEL FISHER ON RECOVERY

When Dr. Daniel Fisher was a neurochemist working for the National Institute of Mental Health in the late 1960s, he was convinced that the key to mental illness was somewhere in the brain's messenger chemicals, which he was studying. But that was before he was hospitalized with schizophrenia and got a first-person perspective.

"I found that thinking that everything was determined by chemistry was very disempowering and very dehumanizing," he said. Fisher, 61, who turned from neuroscience to psychiatry after his own battle with mental illness, is now one of the leading proponents of a view that is about as far from the lab bench as one can get. He believes that with enough of a support system, people can recover fully from mental illness, even from disorders such as schizophrenia that are widely believed to be chronic, long-term illnesses for most people. Psychiatrist To Discuss Recovery Published April 6, 2005 in the Hartford Courant

By GARRET CONDON, Courant Staff Writer

http://www.power2u.org/hartford_courant_5.6.05.htm

National Empowerment Center, Inc.

INTERVIEW WITH DANIEL FISHER

An Empowerment Model of Recovery From Severe Mental Illness: An Expert Interview With Daniel B. Fisher, MD, PhD

Editor's Note: Randall White, MD, interviewed Daniel B. Fisher, MD, PhD, Executive Director of the National Empowerment Center in Lawrence, Massachusetts.

Medscape: In your publication "Personal Assistance in Community Existence: A Recovery Guide," you write that the recovery model emphasizes that emotional distress is a temporary disruption in life.[1] Can you elaborate?

Dr. Fisher: …The most important finding in our research is that people who have shown significant or complete recovery from severe mental illness - - by that I mean schizophrenia, bipolar disorder, or schizoaffective disorder -- have cited hope as an extraordinarily important component in their recovery. Part of the recovery was being around people who saw their condition as not permanent, a condition from which they could take increasing control of their life and reestablish a place in society.

DANIEL FISHER CONT.

Medscape: Your publications make reference to the difference in outcome of schizophrenia in less developed societies compared with industrialized societies. What does the research indicate?

Dr. Fisher: The evidence is from 2 studies by the World Health Organization (WHO), one in 1979 and the second in 1992, comparing the recovery rate, mostly from schizophrenia, in developing countries with the recovery rate in industrialized countries. In 1979, WHO had about 1800 cases validated by Western diagnostic criteria in developing counties matched with controls from industrialized countries, and they found that the recovery rate was roughly twice as high in the developing countries compared with the industrialized.[4] They were so surprised by this that they said, "Well, this must be a big mistake." So they repeated the study in 1992, and they got the same results.[5]

Slide 14

WHAT IS SOTERIA?

ABSTRACT: The author reviews the clinical and special social environmental data from the Soteria Project and its direct successors. Two random assignment studies of the Soteria model and its modification for long-term system clients reveal that roughly 85% to 90% of acute and long-term clients deemed in need of acute hospitalization can be returned to the community without use of conventional hospital treatment. Soteria, designed as a drug free treatment environment, was as successful as antipsychotic drug treatment in reducing psychotic symptoms in 6 weeks. In its modified form, in facilities called Crossing Place and McAuliffe House where so-called long term "frequent flyers" were treated, alternative-treated subjects were found to be as clinically improved as hospital-treated patients, at considerably lower cost. Taken as a body of scientific evidence, it is clear that alternatives to acute psychiatric hospitalization are as, or more, effective than traditional hospital care in short-term reduction of psychopathology and longer- social adjustment. Data from the original drug-free, home-like, nonprofessionally staffed Soteria Project and its Bern, Switzerland, replication indicate that persons without extensive hospitalizations (<30 days) are especially responsive to the positive therapeutic effects of the well-defined, replicable Soteria-type special social environments. Reviews of other studies of diversion of persons deemed in need of hospitalization to "alternative" programs have consistently shown equivalent or better program clinical results, at lower cost, from alternatives. Despite these clinical and cost data, alternatives to psychiatric hospitalization have not been widely implemented, indicative of a remarkable gap between available evidence and clinical practice.

THE JOURNAL OF NERVOUS AND MENTAL DISEASE 187:142-149, 1999

Soteria House Model website

SOTERIA-ALASKA

MISSION

The mission of the Soteria-Alaska Pilot Program would be to effectively and efficiently treat mentally ill individuals within the Alaska community with a quality and cost effective program that demonstrates the effectiveness of an alternative to acute hospitalization and which allows them more choice and flexibility in the initial stages of their illness than a traditional hospital program.

VISION

To effectively use a community and milieu recovery model as the basis of a program to meet the needs of those Alaskan who would respond to such an individualized approach to the treatment of their mental illness, that if proven as a model will provide an additional choice/option for effective treatment.

RECOVERY IN IONIA ALASKA

In 1987, a group of what I think of as refugees from the mental illness system in Massachusetts founded the community and non-profit, Ionia, in Kasilof, Alaska. They pooled their resources and created a lifestyle that totally works for them.22 They now have over 40 people living there, including many children. I don't think they have had a psychiatric crisis in well over ten years, perhaps not since the community was founded. They built their own log houses, eat a strict macrobiotic diet, growing and gathering much of their own food, and meet every morning for as long as it takes to work through any issues. A few years ago, they needed some grant funding to expand their agricultural operation and build a community building they call the "Longhouse." The grant application brought what they were doing to the attention of policy makers, and Ionia became an example of a group of people who, after being pronounced hopelessly and permanently mentally ill, created their own environment, and proved it is possible to recover from a diagnosis of serious mental illness and thrive.

CHOICES

CHOICES, Inc., was formed to provide alternatives in the community to the current medication dominated mental health system… CHOICES is what is known as a Consumer Run program, where "consumer" means someone who has been labeled with a serious mental illness and is a past or present recipient of mental health services. More specifically, … "at least 2/3rds of the members of the Board of Directors shall be a past or present recipient of mental health services of such a nature that inpatient care may have been necessary." The philosophy behind CHOICES is reflected in both its name and the words which create the acronym CHOICES -- Consumers Having Ownership In Creating Effective Services -- which is people having options of their own creation and choosing.

CHOICES, CONT.

Three basic components to the CHOICES:

(1) Helping people (and parents of younger children) get what they want.

(2) Providing the types of services Loren Mosher describes in Chapter 9 of his and Lorenzo Burti's excellent book, Community Mental Health: A Practical Guide, which can be found at http://choices-ak.org/grants/05TBGIOperating /Ch9.pdf.

(3) Being a conduit for pass-through grants for consumer run programs that have not obtained 501(c)(3) status.

CLUBHOUSES

Clubhouses believe that recovery from serious mental illness (SMI) must involve the whole person in a vital and culturally sensitive community within which members (adults with SMI) can receive the supports necessary to lead productive and satisfying lives. Members are involved in all operational aspects of the clubhouse, working side-by-side with staff. Clubhouses offer a range of services including vocational supports, community-based employment (Transitional, Supported, and Independent Employment), education, housing, outreach, advocacy, assistance with accessing health care, substance abuse services, as well as social and recreational opportunities.

CLUBHOUSES - CONT.

Today hundreds of millions of people worldwide are affected by mental illness. People living with serious and persistent mental illness are among the most severely stigmatized and marginalized groups in the world. Human rights violations, poverty, a sense of shame, a lack of education, and restricted opportunities to participate and contribute in society are common.

The International Center for Clubhouse Development (ICCD) was founded in 1994 as a response to this profound international crisis. Our work is to create and nurture sustainable community based resource centers of opportunity and hope for people living with mental illness. These centers are modeled after the very successful Fountain House program in New York City. Here we help people with mental illness participate in society through employment, supported education, a circle of friends; access to needed services (medical and social); and a place to belong. The ICCD is a global network of such centers, called “Clubhouses.”

THE EFFICACY OF THE CLUBHOUSE MODEL

Recent SAMHSA (Substance Abuse and Mental Health Services Administration) supported research has verified the efficacy of the clubhouse model. In this study Clubhouse and PACT, Programs for Assertive Community Treatment, programs were compared to each other. Clubhouse participants were shown to have longer work duration and higher earnings than those in PACT* programs. Clubhouse jobs were of higher quality than those gotten by PACT model programs. And the cost per person was demonstrated to be less in clubhouse than in PACT with as good or better outcomes. Clubhouse not only addresses helping members (clients) get jobs, but also addresses their social needs, a shortfall in other less comprehensive model programs.

60 YEAR HISTORY

The clubhouse model has expanded over its nearly 60-year history in the following ways:

Today there are close to 400 clubhouses in 30 different countries around the world serving over 55,000 people.

In the United States there are 196 clubhouses in 32 states serving approximately 37,500 men and women living with mental illness.

318 clubhouses belong to the International Center for Clubhouse Development (ICCD) and 150 are ICCD Certified Clubhouses.

20 new clubhouses open each year with the assistance of International Training Bases, located in New York, Massachusetts, South Carolina, Missouri, Toronto, London, Sweden, South Korea, Finland and Australia.

120 new teams of clubhouse staff are trained each year.

Recently, the United Nations gave the International Center for Clubhouse Development “Special Consultative Status” with the United Nations Economic and Social Committee (ECOSOC). ICCD is the only international mental health organization with this status.

COMMUNITY MENTAL HEALTH 24-HOUR MOBILE CRISES TEAM

WE BELIEVE THAT THE 24-HOUR MOBILE CRISES intervention team should be the center of every community mental health program. In most situations it will function as the gatekeeper to the system. Systematic research on the use of 24-hour mobile crises teams has shown that they reduce hospitalization by at least 50%. The experience in South Verona (Italy).

If a home intervention is thought to be necessary the team advises the caller of the plan and asks for his or her reaction. If the plan is acceptable, the caller is asked to assemble the parties relevant to the problem and told that the team will arrive in about 15-20 minutes. If it is a call from police on site, they are asked to stay also. A minimum of two team members, preferably a male and a female, should respond… On arrival the team evaluates the nature of the problem utilizing interview techniques…. The actual intervention will use a variety of techniques ….

24-HOUR MOBILE CRISES TEAM – CONT.

Alternatives to Hospitalization

In a properly designed and functioning community mental health system community residential treatment facilities should sere the vast majority of disturbed and disturbing individuals in need of intensive interpersonal care who cannot be adequately treated by in-home crises intervention. Use of these small home-like facilities in conjunction with 24-hour mobile crises intervention will dramatically reduce the need for psychiatric beds in hospitals.

[These are references taken from Chapter 9, A Community Services Smorgasbord, from The book Community Mental Health by Mosher L.R. & Burti L. (1992) Community Mental Health Chuo Hoki Suppen: Tokio

FROM PRIVILEGES TO RIGHTS:
PEOPLE LABELLED WITH PSYCHIATRIC DISABILITIES SPEAK FOR THEMSELVES

National Council on Disability, January 20, 2000

Recommendations

. . . NCD has developed 10 core recommendations in this report. These policy recommendations should be viewed from the context of the larger report, which follows. These deeply held core beliefs form, however, a dynamic backdrop to highlight the human and civil rights of people who have experienced the mental health system, people who should be viewed as the true experts on their experiences, beliefs, and values, which should be used as a guiding force for changing public policy related to these issues in America.

1. Laws that allow the use of involuntary treatments such as forced drugging and inpatient and outpatient commitment should be viewed as inherently suspect, because they are incompatible with the principle of self-determination. Public policy needs to move in the direction of a totally voluntary community-based mental health system that safeguards human dignity and respects individual autonomy.

PRIVILEGES TO RIGHTS – CONT.

2. People labeled with psychiatric disabilities should have a major role in the direction and control of programs and services designed for their benefit. This central role must be played by people labeled with psychiatric disabilities themselves, and should not be confused with the roles that family members, professional advocates, and others often play when "consumer" input is sought.

3. Mental health treatment should be about healing, not punishment. Accordingly, the use of aversive treatments, including physical and chemical restraints, seclusion, and similar techniques that restrict freedom of movement, should be banned. Also, public policy should move toward the elimination of electro-convulsive therapy and psycho surgery as unproven and inherently inhumane procedures. Effective humane alternatives to these techniques exist now and should be promoted.

4. Federal research and demonstration resources should place a higher priority on the development of culturally appropriate alternatives to the medical and biochemical approaches to treatment of people labeled with psychiatric disabilities, including self-help, peer support, and other consumer/survivor-driven alternatives to the traditional mental health

WHY THE CURRENT TREATMENT SYSTEM FAILS

Low expectations in the mental health system are both a cause and an effect of decades of low results. If less than 1% of clients are actually recovering from their alleged ‘illnesses,’ then we must begin to examine both the theories upon which their treatment is based and the actual effects of the treatment. The treatment of mental and emotional difficulties is based upon the theory that such problems are the result of chemical imbalance in the brain. Hence psychiatric drug treatment forms the core of all treatment programs. But if psychotropic drugs really do correct the chemical imbalance that is the source of the problem, why are so few recovering?

The answer is twofold. First, there is no proof that those who have been labeled mentally ill are actually suffering from a chemical imbalance. An increasing number of psychiatrists and neuroscientists are now arguing that the “chemical imbalance’’ theory is scientifically unsound. Second, the cornerstone of psychiatry’s medical model of the human condition has not been proven and the evidence for it is very weak. In essence, clients of the mental health system are receiving ‘treatment’ for a condition they do not have, while the actual sources of their problems are largely ignored.

WHY THE CURRENT TREATMENT SYSTEM FAILS – CONT.

There are two major consequences of this misguided approach. First, individuals spend years on drugs that actually produce chemical imbalances in the brain. These drugs weaken and damage many of the body’s vital organs, resulting in deteriorating physical health. The drugs also have an enormous psychological impact on the individual, commonly producing the depressive or psychotic symptoms for which they are prescribed. The result is that the drugs lead the individual away from recovery and toward chronic illness.

The second consequence is the actual source of the problem is left untreated. That source is frequently a real physical illness that has not been discovered and is either directly producing the mental and emotional effects or exacerbating them. Mental & emotional effects can also be produced by numerous other physiological conditions, including reactions to medications, nutritional deficiencies, hormonal imbalances, and toxic and allergic reactions. A simple lack of exercise can play a significant role. In addition, there are numerous social and psychological factors that play an obvious role in our mental and emotional well being.

PROPER MEDICAL EXAMINATION

"As a practicing psychiatrist and neurologist, I've successfully diagnosed and treated hundreds of patients whose emotional and behavioral symptoms were caused by tumors, infections, toxins, medication errors, genetic diseases, and other physical problems. Most of them came to me after being tagged with psychiatric labels - manic depression, anxiety disorder, attention deficit disorder – and being given powerful mind-altering drugs or referral for psychotherapy. By the time they called my office, many were desperate, some were suicidal, and few had been significantly helped."

Finding the Medical Causes of Severe Mental Symptoms: The Extraordinary Walker Exam by Dan Stradford Founder, Safe Harbor Project

PROPER MEDICAL
EXAMINATION – CONT.

For several reasons, mental health professionals working within a mental health system have a professional and a legal obligation to recognize the presence of physical disease in their patients. First, physical diseases may cause a patient's mental disorder. Second, physical disease may worsen a mental disorder, either by affecting brain function or by giving rise to a psychopathologic reaction. Third, mentally ill patients are often unable or unwilling to seek medical care and may harbor a great deal of undiscovered physical disease. Finally, a patient's visit to a mental health program creates an opportunity to screen for physical disease in a symptomatic population. The yield of disease from such screening is usually higher than the yield in an asymptomatic population. By Lorrin M. Koran, M.D., Department of Psychiatry and Behavioral Sciences, Stanford University Medical Center Stanford, California 1991

"As PACT is not a..."

As PACT is not a recovery program and does not represent CHOICES, PACT in any form should not be funded and if passed by the legislature should be vetoed.

This presentation was created by

Carole Willey

Clifford Thurston and

Steven Pearce


	The fundamental problem with the current mental health system is that virtually no one recovers their health and very few are even making progress toward recovery. [Reference King County RSN Recovery Model report for 2001, 2002 and 2003 less than 1% recover their health. This King County ordinance is or rather was (it was modified and no longer tracks recovery of health) unique in the state of Washington. No other RSN, nor the MHD tracks recovery of health]
	The public mental health system can be deemed to be a system of maintaining individuals in their chronic mental illness. [Reference: CCHR White Paper on CREATING CHRONIC ILLNESS, August 2004]
	This places a tremendous burden on the public mental health system to meet existing demand, yet still be required to service anyone new to the system who is Medicaid eligible.


	There are several “reform” efforts underway. The Mental Health Task Force spawned HB 1290 and SB 5763. We also now have the Mental Health Transformation Grant with it’s subcommittees meeting around the state currently.
	One of the issues being pushed are “Evidence Based Practices”.
	PACT appears to be being pushed, because it is being called an Evidence Based Practice.


	PACT stands for Program of Assertive Community Treatment. Notice the word assertive. One of the main goals is ensuring treatment compliance.
	A PACT team can include: generalist staff trained as registered nurses, clinical psychologists, case managers, substance abuse specialists, occupational therapists, and vocational specialists, in addition to part-time psychiatrists.
	P/ACT [PACT is known by other names, i.e. without the P as ACT) was originally developed as an alternative to psychiatric hospitalization, with the goal of allowing people to live independently in the community. But, in reality, P/ACT has evolved into a coercive, lifelong and non-client*-directed system with medication compliance as its most basic tenet.


	PACT does not solve the system-wide problem that people are not recovering their health – their dependence is being maintained.
	According to the analysis of PACT in Clark County the mean GAF score is 54.3 which is in the “moderate” category. The range of this score appears to be 41.2 to 67.4. This means individuals symptoms range from serious to moderate – but nevertheless in the dependent to less dependent category – not recovered.


	For the years 2001 through 2003 King County RSN reported annually on outcomes based largely upon GAF (Global Assessment of Functioning) scores. Clients were rated as:
			Recovered above 81
			Less Dependent 51 to 81 – mild to moderate symptoms or
			Dependent less than 51 – serious symptoms
	GAF scores are part of Medicaid eligibility requirements in Washington State. They are a widely accepted measure of mental health. You can see this scale on the following pages.


	Superior functioning in a wide range of activities, life’s problems never seem to get out of hand, is sought out by others because of his or her many positive qualities. No symptoms.

	Absent or minimal symptoms (e.g., mild anxiety before an exam), good functioning in all areas, interested and involved in a wide range of activities, socially effective, generally satisfied with life, no more than everyday problems or concerns (e.g., an occasional argument with family members).

	If symptoms are present, they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument); no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork).

	Some mild symptoms (e.g., depressed mood and mild insomnia) OR some difficulty in social, occupational or school functioning (e.g., occasional truancy or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships.

	Moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) OR moderate difficulty in social, occupational or school functioning (e.g., few friends, conflicts with peers or co-workers).

	Cont on next slide (slide 5)


	Chapter 4 ● Transformation Goals, Objectives, Strategies and Performance Measures
	B. IMPROVE CONSUMER SELF-SUFFICIENCY – PUBLIC VALUE
	Goal 2: Mental health care is consumer and caregiver driven, with consumers, families, caregivers and advocates involved in individual recovery and resiliency process.
	Develop and implement concepts and programs that prioritize goals and outcomes that foster autonomy rather than maintenance and codependency.

	Strategic Plan 2006-2011 Mental Health Division


	When Dr. Daniel Fisher was a neurochemist working for the National Institute of Mental Health in the late 1960s, he was convinced that the key to mental illness was somewhere in the brain's messenger chemicals, which he was studying. But that was before he was hospitalized with schizophrenia and got a first-person perspective.
	"I found that thinking that everything was determined by chemistry was very disempowering and very dehumanizing," he said. Fisher, 61, who turned from neuroscience to psychiatry after his own battle with mental illness, is now one of the leading proponents of a view that is about as far from the lab bench as one can get. He believes that with enough of a support system, people can recover fully from mental illness, even from disorders such as schizophrenia that are widely believed to be chronic, long-term illnesses for most people. Psychiatrist To Discuss Recovery Published April 6, 2005 in the Hartford Courant
					By GARRET CONDON, Courant Staff Writer
					http://www.power2u.org/hartford_courant_5.6.05.htm
					National Empowerment Center, Inc.


	An Empowerment Model of Recovery From Severe Mental Illness: An Expert Interview With Daniel B. Fisher, MD, PhD

	Editor's Note: Randall White, MD, interviewed Daniel B. Fisher, MD, PhD, Executive Director of the National Empowerment Center in Lawrence, Massachusetts.

	Medscape: In your publication "Personal Assistance in Community Existence: A Recovery Guide," you write that the recovery model emphasizes that emotional distress is a temporary disruption in life.[1] Can you elaborate?
	Dr. Fisher: …The most important finding in our research is that people who have shown significant or complete recovery from severe mental illness - - by that I mean schizophrenia, bipolar disorder, or schizoaffective disorder -- have cited hope as an extraordinarily important component in their recovery. Part of the recovery was being around people who saw their condition as not permanent, a condition from which they could take increasing control of their life and reestablish a place in society.


	Medscape: Your publications make reference to the difference in outcome of schizophrenia in less developed societies compared with industrialized societies. What does the research indicate?

	Dr. Fisher: The evidence is from 2 studies by the World Health Organization (WHO), one in 1979 and the second in 1992, comparing the recovery rate, mostly from schizophrenia, in developing countries with the recovery rate in industrialized countries. In 1979, WHO had about 1800 cases validated by Western diagnostic criteria in developing counties matched with controls from industrialized countries, and they found that the recovery rate was roughly twice as high in the developing countries compared with the industrialized.[4] They were so surprised by this that they said, "Well, this must be a big mistake." So they repeated the study in 1992, and they got the same results.[5]


	ABSTRACT: The author reviews the clinical and special social environmental data from the Soteria Project and its direct successors. Two random assignment studies of the Soteria model and its modification for long-term system clients reveal that roughly 85% to 90% of acute and long-term clients deemed in need of acute hospitalization can be returned to the community without use of conventional hospital treatment. Soteria, designed as a drug free treatment environment, was as successful as antipsychotic drug treatment in reducing psychotic symptoms in 6 weeks. In its modified form, in facilities called Crossing Place and McAuliffe House where so-called long term "frequent flyers" were treated, alternative-treated subjects were found to be as clinically improved as hospital-treated patients, at considerably lower cost. Taken as a body of scientific evidence, it is clear that alternatives to acute psychiatric hospitalization are as, or more, effective than traditional hospital care in short-term reduction of psychopathology and longer- social adjustment. Data from the original drug-free, home-like, nonprofessionally staffed Soteria Project and its Bern, Switzerland, replication indicate that persons without extensive hospitalizations (<30 days) are especially responsive to the positive therapeutic effects of the well-defined, replicable Soteria-type special social environments. Reviews of other studies of diversion of persons deemed in need of hospitalization to "alternative" programs have consistently shown equivalent or better program clinical results, at lower cost, from alternatives. Despite these clinical and cost data, alternatives to psychiatric hospitalization have not been widely implemented, indicative of a remarkable gap between available evidence and clinical practice.
	THE JOURNAL OF NERVOUS AND MENTAL DISEASE 187:142-149, 1999
	Soteria House Model website


	MISSION
	The mission of the Soteria-Alaska Pilot Program would be to effectively and efficiently treat mentally ill individuals within the Alaska community with a quality and cost effective program that demonstrates the effectiveness of an alternative to acute hospitalization and which allows them more choice and flexibility in the initial stages of their illness than a traditional hospital program.

	VISION
	To effectively use a community and milieu recovery model as the basis of a program to meet the needs of those Alaskan who would respond to such an individualized approach to the treatment of their mental illness, that if proven as a model will provide an additional choice/option for effective treatment.


	In 1987, a group of what I think of as refugees from the mental illness system in Massachusetts founded the community and non-profit, Ionia, in Kasilof, Alaska. They pooled their resources and created a lifestyle that totally works for them.22 They now have over 40 people living there, including many children. I don't think they have had a psychiatric crisis in well over ten years, perhaps not since the community was founded. They built their own log houses, eat a strict macrobiotic diet, growing and gathering much of their own food, and meet every morning for as long as it takes to work through any issues. A few years ago, they needed some grant funding to expand their agricultural operation and build a community building they call the "Longhouse." The grant application brought what they were doing to the attention of policy makers, and Ionia became an example of a group of people who, after being pronounced hopelessly and permanently mentally ill, created their own environment, and proved it is possible to recover from a diagnosis of serious mental illness and thrive.


	Three basic components to the CHOICES:

	(1) Helping people (and parents of younger children) get what they want.
	(2) Providing the types of services Loren Mosher describes in Chapter 9 of his and Lorenzo Burti's excellent book, Community Mental Health: A Practical Guide, which can be found at http://choices-ak.org/grants/05TBGIOperating /Ch9.pdf.
	(3) Being a conduit for pass-through grants for consumer run programs that have not obtained 501(c)(3) status.


	Today hundreds of millions of people worldwide are affected by mental illness. People living with serious and persistent mental illness are among the most severely stigmatized and marginalized groups in the world. Human rights violations, poverty, a sense of shame, a lack of education, and restricted opportunities to participate and contribute in society are common.
	The International Center for Clubhouse Development (ICCD) was founded in 1994 as a response to this profound international crisis. Our work is to create and nurture sustainable community based resource centers of opportunity and hope for people living with mental illness. These centers are modeled after the very successful Fountain House program in New York City. Here we help people with mental illness participate in society through employment, supported education, a circle of friends; access to needed services (medical and social); and a place to belong. The ICCD is a global network of such centers, called “Clubhouses.”



	Recent SAMHSA (Substance Abuse and Mental Health Services Administration) supported research has verified the efficacy of the clubhouse model. In this study Clubhouse and PACT, Programs for Assertive Community Treatment, programs were compared to each other. Clubhouse participants were shown to have longer work duration and higher earnings than those in PACT* programs. Clubhouse jobs were of higher quality than those gotten by PACT model programs. And the cost per person was demonstrated to be less in clubhouse than in PACT with as good or better outcomes. Clubhouse not only addresses helping members (clients) get jobs, but also addresses their social needs, a shortfall in other less comprehensive model programs.


	The clubhouse model has expanded over its nearly 60-year history in the following ways:
	Today there are close to 400 clubhouses in 30 different countries around the world serving over 55,000 people.
	In the United States there are 196 clubhouses in 32 states serving approximately 37,500 men and women living with mental illness.
	318 clubhouses belong to the International Center for Clubhouse Development (ICCD) and 150 are ICCD Certified Clubhouses.
	20 new clubhouses open each year with the assistance of International Training Bases, located in New York, Massachusetts, South Carolina, Missouri, Toronto, London, Sweden, South Korea, Finland and Australia.
	120 new teams of clubhouse staff are trained each year.
	Recently, the United Nations gave the International Center for Clubhouse Development “Special Consultative Status” with the United Nations Economic and Social Committee (ECOSOC). ICCD is the only international mental health organization with this status.



	WE BELIEVE THAT THE 24-HOUR MOBILE CRISES intervention team should be the center of every community mental health program. In most situations it will function as the gatekeeper to the system. Systematic research on the use of 24-hour mobile crises teams has shown that they reduce hospitalization by at least 50%. The experience in South Verona (Italy).
	If a home intervention is thought to be necessary the team advises the caller of the plan and asks for his or her reaction. If the plan is acceptable, the caller is asked to assemble the parties relevant to the problem and told that the team will arrive in about 15-20 minutes. If it is a call from police on site, they are asked to stay also. A minimum of two team members, preferably a male and a female, should respond… On arrival the team evaluates the nature of the problem utilizing interview techniques…. The actual intervention will use a variety of techniques ….


	Alternatives to Hospitalization
	In a properly designed and functioning community mental health system community residential treatment facilities should sere the vast majority of disturbed and disturbing individuals in need of intensive interpersonal care who cannot be adequately treated by in-home crises intervention. Use of these small home-like facilities in conjunction with 24-hour mobile crises intervention will dramatically reduce the need for psychiatric beds in hospitals.

	[These are references taken from Chapter 9, A Community Services Smorgasbord, from The book Community Mental Health by Mosher L.R. & Burti L. (1992) Community Mental Health Chuo Hoki Suppen: Tokio


	National Council on Disability, January 20, 2000
	Recommendations
	. . . NCD has developed 10 core recommendations in this report. These policy recommendations should be viewed from the context of the larger report, which follows. These deeply held core beliefs form, however, a dynamic backdrop to highlight the human and civil rights of people who have experienced the mental health system, people who should be viewed as the true experts on their experiences, beliefs, and values, which should be used as a guiding force for changing public policy related to these issues in America.
	1. Laws that allow the use of involuntary treatments such as forced drugging and inpatient and outpatient commitment should be viewed as inherently suspect, because they are incompatible with the principle of self-determination. Public policy needs to move in the direction of a totally voluntary community-based mental health system that safeguards human dignity and respects individual autonomy.


	2. People labeled with psychiatric disabilities should have a major role in the direction and control of programs and services designed for their benefit. This central role must be played by people labeled with psychiatric disabilities themselves, and should not be confused with the roles that family members, professional advocates, and others often play when "consumer" input is sought.
	3. Mental health treatment should be about healing, not punishment. Accordingly, the use of aversive treatments, including physical and chemical restraints, seclusion, and similar techniques that restrict freedom of movement, should be banned. Also, public policy should move toward the elimination of electro-convulsive therapy and psycho surgery as unproven and inherently inhumane procedures. Effective humane alternatives to these techniques exist now and should be promoted.
	4. Federal research and demonstration resources should place a higher priority on the development of culturally appropriate alternatives to the medical and biochemical approaches to treatment of people labeled with psychiatric disabilities, including self-help, peer support, and other consumer/survivor-driven alternatives to the traditional mental health


	Low expectations in the mental health system are both a cause and an effect of decades of low results. If less than 1% of clients are actually recovering from their alleged ‘illnesses,’ then we must begin to examine both the theories upon which their treatment is based and the actual effects of the treatment. The treatment of mental and emotional difficulties is based upon the theory that such problems are the result of chemical imbalance in the brain. Hence psychiatric drug treatment forms the core of all treatment programs. But if psychotropic drugs really do correct the chemical imbalance that is the source of the problem, why are so few recovering?
	The answer is twofold. First, there is no proof that those who have been labeled mentally ill are actually suffering from a chemical imbalance. An increasing number of psychiatrists and neuroscientists are now arguing that the “chemical imbalance’’ theory is scientifically unsound. Second, the cornerstone of psychiatry’s medical model of the human condition has not been proven and the evidence for it is very weak. In essence, clients of the mental health system are receiving ‘treatment’ for a condition they do not have, while the actual sources of their problems are largely ignored.


	There are two major consequences of this misguided approach. First, individuals spend years on drugs that actually produce chemical imbalances in the brain. These drugs weaken and damage many of the body’s vital organs, resulting in deteriorating physical health. The drugs also have an enormous psychological impact on the individual, commonly producing the depressive or psychotic symptoms for which they are prescribed. The result is that the drugs lead the individual away from recovery and toward chronic illness.
	The second consequence is the actual source of the problem is left untreated. That source is frequently a real physical illness that has not been discovered and is either directly producing the mental and emotional effects or exacerbating them. Mental & emotional effects can also be produced by numerous other physiological conditions, including reactions to medications, nutritional deficiencies, hormonal imbalances, and toxic and allergic reactions. A simple lack of exercise can play a significant role. In addition, there are numerous social and psychological factors that play an obvious role in our mental and emotional well being.


	"As a practicing psychiatrist and neurologist, I've successfully diagnosed and treated hundreds of patients whose emotional and behavioral symptoms were caused by tumors, infections, toxins, medication errors, genetic diseases, and other physical problems. Most of them came to me after being tagged with psychiatric labels - manic depression, anxiety disorder, attention deficit disorder – and being given powerful mind-altering drugs or referral for psychotherapy. By the time they called my office, many were desperate, some were suicidal, and few had been significantly helped."
	Finding the Medical Causes of Severe Mental Symptoms: The Extraordinary Walker Exam by Dan Stradford Founder, Safe Harbor Project


	As PACT is not a recovery program and does not represent CHOICES, PACT in any form should not be funded and if passed by the legislature should be vetoed.

	This presentation was created by
	Carole Willey
	Clifford Thurston and
	Steven Pearce