What is Positive Disintegration?

Introduction

The theory of positive disintegration (TPD) by Kazimierz Dąbrowski is a theory of personality development.

Unlike some other theories of development such as Erikson’s stages of psychosocial development, it is not assumed that even a majority of people progress through all levels. TPD is not a theory of stages, and levels do not correlate with age.

Unlike mainstream psychology, Dąbrowski’s theoretical framework views psychological tension and anxiety as necessary for growth. These “disintegrative” processes are therefore seen as “positive”, whereas people who fail to go through positive disintegration may remain for their entire lives in a state of “primary integration”, lacking true individuality. Advancing into disintegration and into the higher levels of development is predicated on having developmental potential, including overexcitabilities, above-average reactions to stimuli.

Dąbrowski’s Theory

Kazimierz Dąbrowski (1902-1980), a Polish psychiatrist and psychologist, developed the Theory of Positive Disintegration which led to the 1964 publication of the eponymous book, Positive Disintegration. He believed that the key to the treatment of mental illness was intense personal suffering and hence singled out the self-infliction of suffering as essential to personal development.

Dąbrowski’s theory of personality development emphasised several major features including:

  • Personality is not a given universal trait, it must be created – shaped – by the individual to reflect his or her own unique character (personality shaping)
  • Personality develops as a result of the action of developmental potential (DP) (overexcitability and the autonomous factor), not everyone displays sufficient DP to create a unique personality.
  • Developmental potential is represented in the population by a normal (bell) curve. Dąbrowski used a multilevel approach to describe the continuum of developmental levels seen in the population.
  • Developmental potential creates crises characterized by strong anxieties and depressions – psychoneurosis – that precipitate disintegration
  • for personality to develop, initial integrations based on instinct and socialisation must disintegrate – a process Dąbrowski called positive disintegration
  • The development of a hierarchy of individual values – emotional reactions – is a critical component in developing one’s personality and one’s autonomy, thus, in contrast to most psychological theories, emotions play a major role in this approach
  • Emotional reactions guide the individual in creating his or her individual personality ideal, an autonomous standard that acts as the goal of individual development
  • The individual must examine his or her essence and subsequently make existential choices that emphasize those aspects of essence that are higher and “more myself” and inhibit those aspects that are lower or “less myself” based upon his or her own personality ideal
  • Critical components of individual development include autoeducation and autopsychotherapy

Factors in Personality Development

Dąbrowski observed that most people live their lives in a state of “primary or primitive integration” largely guided by biological impulses (“first factor”) and/or by uncritical endorsement and adherence to social conventions (“second factor”). He called this initial integration Level I. Dąbrowski observed that at this level there is no true individual expression of the autonomous human self. Individual expression at Level I is influenced and constrained by the first two factors.

The first factor channels energy and talents toward accomplishing self-serving goals that reflect the “lower instincts” and biological ego – its primary focus is on survival and self-advancement. Often talents are used in antisocial or asocial ways. For example, at the lowest edge of Level I many criminals display this type of selfish behaviour. They tend to advance their own goals at the expense of others.

The second factor, the social environment (milieu) and peer pressure, constrains individual expression and creativity by encouraging a group view of life and discouraging individual thought and expression. The second factor externalises values and morals, thereby externalising conscience. Social forces shape expectations. Behaviour and one’s talents and creativity are funnelled into forms that follow and support the existing social milieu. “My mom says we should always be aware of what our lawn looks like because we want other people to think well of us when they drive by.” Because conscience is derived from an external social context, so long as society holds ethical standards, people influenced by the second factor will behave ethically. However, if a society becomes corrupt, people strongly influenced by second factor will not dissent. Socialisation without individual examination leads to a rote and robotic existence (the “robopath” described by Ludwig von Bertalanffy). Individual reactions are not unique, they are based upon social contexts (“I cry at funerals and laugh at weddings—everyone does”). According to Dąbrowski, people primarily motivated by second factor represent a significant majority of the general population.

Dąbrowski felt that society was largely influenced by the two lower factors and could be characterised as operating at Level I. For example, society’s emphasis on corporate success (“a dog eat dog mentality”) means that many CEOs operate on the basis of first factor – they will quickly sacrifice another to enhance their own advancement. As well, society’s educational, political, corporate, and media systems are self-promoting and discourage real examination or individual autonomy – the second factor. Alternatively, social justifications are often used: “Of course I break the speed limit, everyone does.” Or a soldier may explain that he or she was simply “following orders”. Thus, this external value system absolves the individual of any individual responsibility.

Dąbrowski also described a group of people who display a different course: an individualised developmental pathway. Such people break away from an automatic, rote, socialised view of life (which Dąbrowski called negative adjustment) and are said to move into and through a series of personal disintegrations. Dąbrowski saw these disintegrations as a key element in the overall developmental process. Crises challenge the status quo and cause people to review the self, ideas, values, thoughts, ideals, etc. If development continues, one goes on to develop an individualised, conscious and critically evaluated hierarchical value structure (called positive adjustment). This hierarchy of values acts as a benchmark by which all things are now seen, and the higher values in society’s internal hierarchy come to direct behaviour (no longer based on external social mores). These higher, individual values characterise an eventual second integration reflecting individual autonomy and for Dąbrowski, mark the arrival of true human personality. At this level, each person develops his or her own vision of how life ought to be and lives it. This higher level is associated with strong individual approaches to problem solving and creativity. One’s talents and creativity are applied in the service of these higher individual values and visions of how life could be – how the world ought to be. The person expresses his or her “new” autonomous personality energetically through action, art, social change, and so on.

Development Potential

Advanced development is often seen in people who exhibit strong developmental potential (“DP”). Developmental potential represents a constellation of genetic features, expressed and mediated through environmental interaction. Many factors are incorporated in developmental potential but three major aspects are highlighted: overexcitability (OE), specific abilities and talents, and a strong drive toward autonomous growth, a feature Dąbrowski called the “third factor”.

Overexcitability

The most evident aspect of developmental potential is overexcitability (OE), a heightened physiological experience of stimuli resulting from increased neuronal sensitivities. The greater the OE, the more intense are the day-to-day experiences of life. Dąbrowski outlined five forms of OE:

  • Psychomotor;
  • Sensual;
  • Imaginational;
  • Intellectual; and
  • Emotional.

These overexcitabilities, especially the latter three, often cause a person to experience daily life more intensely and to feel the extremes of the joys and sorrows of life profoundly. Dąbrowski studied human exemplars and found that heightened overexcitability was a key part of their developmental and life experience. These people are steered and driven by their value “rudder”, their sense of emotional OE. Combined with imaginational and intellectual OE, these people have a powerful perception of the world.

Although based in the nervous system, overexcitabilities come to be expressed psychologically through the development of structures that reflect the emerging autonomous self. The most important of these conceptualisations are dynamisms: biological or mental forces that control behaviour and its development. Instincts, drives, and intellectual processes combined with emotions are dynamisms. With advanced development, dynamisms increasingly reflect movement toward autonomy.

Abilities and Talents

The second aspect of developmental potential, specific abilities, and talents tends to serve the person’s developmental level. As outlined, people at lower levels use talents to support egocentric goals or to climb the social and corporate ladders. At higher levels, specific talents and abilities become an important force as they are channelled by the person’s value hierarchy into expressing and achieving the person’s vision of his or her ideal personality and his or her view of how the world ought to be.

The Third Factor

The third aspect of developmental potential (DP), which is simply referred to as ‘the third factor’, is a drive toward individual growth and autonomy. The third factor is critical as it applies one’s talents and creativity toward autonomous expression, and second, it provides motivation to strive for more and to try to imagine and achieve goals currently beyond one’s grasp. Dąbrowski was clear to differentiate third factor from free will. He felt that free will did not go far enough in capturing the motivating aspects that he attributed to third factor. For example, an individual can exercise free will and show little motivation to grow or change as an individual. Third factor specifically describes a motivation – a motivation to become one’s self. This motivation is often so strong that, in some situations, one can observe that one needs to develop oneself and that in so doing, it places one at great peril. This feeling of “I’ve gotta be me” especially when it is “at any cost” and especially when it is expressed as a strong motivator for self-growth is beyond the usual conceptualization ascribed to free will.

A person whose DP is high enough will generally undergo disintegration, despite any external social or family efforts to prevent it. A person whose DP is low will generally not undergo disintegration (or positive personality growth) even in a conducive environment.

The notion that some people have an innate potential for development that is determined by a higher sensitivity or overexcitability (analogous to the first aspect of DP) and by a related tendency to develop individual differences and autonomy from the group (analogous to the third aspect of DP) was independently developed by Elaine Aron (see Highly sensitive person) (although Aron’s approach is substantially different from Dąbrowski’s).

Developmental Obstacles

Dąbrowski called OE “a tragic gift” to reflect that the road of the person with strong OE is not a smooth or easy one. Potentials to experience great highs are also potentials to experience great lows. Similarly, potentials to express great creativity hold the likelihood of experiencing a great deal of personal conflict and stress. This stress both drives development and is a result of developmental conflicts, both intrapsychic and social. Suicide is a significant risk in the acute phases of this stress. The isolation often experienced by these people heightens the risk of self-harm.

Dąbrowski advocated autopsychotherapy, educating the person about OEs and the disintegrative process to give him or her a context within which to understand intense feelings and needs. Dąbrowski suggested giving people support in their efforts to develop and find their own self-expression. Children and adults with high DP have to find and walk their own path, often at the expense of fitting in with their social peers and even with their families. At the core of autopsychotherapy is the awareness that no one can show anyone else the “right” path. Everyone has to find their own path for themselves. Alluding to the knights on the Grail Quest, the Jungian analyst, Joseph Campbell allegedly said: “If a path exists in the forest, don’t follow it, for though it took someone else to the Grail, it will not take you there, because it is not your path”.

The Levels

The first and fifth levels are characterised by psychological integration, harmony, and little inner conflict. There is little internal conflict at Level I because just about every behaviour is justified – it is either good for the individual and is therefore “right”, or the individual’s society endorses it and it is therefore “right”. In either case, with a high level of confidence the individual acts as he or she perceives anyone else would, and does what anyone is “supposed to do”. At Level V there is no internal conflict because what a person does is always in accord with their own internal sense of values. Of course, there is often external conflict at both Levels I and V.

Levels II, III, and IV describe various degrees and types of disintegration and literal disease.

Dąbrowski was very clear that the levels he presents “represent a heuristic device”. In the process of development the structures of two or even three contiguous levels may exist side by side, although it must be understood that they exist in conflict. The conflict is resolved when one of the structures is eliminated, or at least comes under complete control of another structure.

Level I: Primary Integration

As outlined above, the first level is called primitive or primary integration. People at this level are often influenced primarily by either prominent first factor (heredity/impulse) and/or second factor (social environment) forces. The majority of people at Level I are integrated at the environmental or social level (Dąbrowski called them average people); however, many also exhibit shades of both impulse and socialization. Dąbrowski distinguished the two subgroups of Level I by degree: “the state of primary integration is a state contrary to mental health. A fairly high degree of primary integration is present in the average person; a very high degree of primary integration is present in the psychopath”.[9] Marked by selfishness and egocentrism (both reticent and explicit), those at level one development generally seek self-fulfilment above all, justifying their pursuits through a sort of “it’s all about me” thinking; or, more simply put, they adhere strongly to the phrase “the end justifies the means”, sometimes disregarding the severity of the “means”. Many people who are considered “leaders” often fall into this category.

A vast majority of people either do not break down their primitive integration at all or after a relatively short period of disintegration, usually experienced at the time of adolescence and early youth, end in a reintegration at the former level or in partial integration of some of the functions at slightly higher levels, without a transformation of the whole mental structure. Primary integration in the average person was proposed to be of a certain value due to its stability and predictability, and when accompanied by kindness and good-will, could represent persons who can provide support and stability to those experiencing disintegration.

Level II: Unilevel Disintegration

The prominent feature of this level is an initial, brief and often intense crisis or series of crises. Crises are spontaneous and occur on only one level. These crises involve alternatives that may appear to be different but ultimately are on the same level.

Unilevel disintegration occurs during developmental crises such as puberty or menopause, in periods of difficulty in handling some stressful external event, or under psychological and psychopathological conditions such as nervousness and psychoneurosis. Unilevel disintegration consists of processes on a single structural and emotional level; there is a prevalence of automatic dynamisms with only slight self-consciousness and self-control.

Conflicts on the same level (horizontal) produce ambitendencies and ambivalences: the person is equally attracted by different but equivalent choices on the same level (ambitendencies) and is not able to decide what to do because he or she has no real preference between the choices (ambivalences). If developmental forces are strong enough, ultimately, the person is thrust into an existential crisis: one’s social rationales no longer account for one’s experiences and there are no alternative explanations. During this phase, existential despair is the predominant emotion. The resolution of this phase begins as individually chosen values begin to replace social mores that have been ingrained by rote and are integrated into a new hierarchy of personal values. These new values often conflict with the person’s previous social values. Many of the status quo explanations for the “way things are,” learned through education and from the social order, collapse under conscious, individual scrutiny. This causes more conflicts focused on the person’s analysis of his or her own reactions to the world at large and of the behaviour of self and others. Common behaviours and the ethics of the prevailing social order come to be seen as inadequate, wrong or hypocritical. Positive maladjustment prevails. For Dąbrowski, these crises represent a strong potential for development toward personal growth and mental health. Using a positive definition, mental health reflects more than social conformity: it involves a careful, personal examination of the world and of one’s values, leading to the development of an individual personality.

Level II is a transitional period. Dąbrowski said you either fall back (reintegration on a lower level), end negatively, in suicide or psychosis or move ahead to Level III.

The transition from Level II to Level III involves a fundamental shift that requires a phenomenal amount of energy. This period is the crossroads of development: from here one must either progress or regress. The struggle between Dąbrowski’s three factors reflects this transitional crisis: “Do I follow my instincts (first factor), my teachings (second factor) or my heart (third factor)?” The developmental answer is to transform one’s lower instincts (automatic reactions like anger) into positive motivation, to resist rote and social answers, and to listen to one’s inner sense of what one ought to do.

Level III: Spontaneous Multilevel Disintegration

Level III describes a new type of conflict: a vertical conflict between two alternatives that are not simply different, but that exist on different levels. One is genuinely higher and the other is lower in comparison. These vertical conflicts initially arise from involuntary perceptions of higher versus lower choices in life.

“You just look at something, maybe for the 1000th time (to use the words of G. K. Chesterton), and it strikes you—you see this one thing differently and once you do, it changes things. You can no longer ‘go back and see it the way you did before.'”

Dąbrowski called this vertical dimension multilevelness. Multilevelness is a gradual realisation of the “possibility of the higher” (a phrase Dąbrowski used frequently) and of the subsequent contrasts between the higher and the lower in life. These vertical comparisons often illustrate the lower, actual behaviour of a person in contrast to higher, imagined ideals and alternative idealised choices. Dąbrowski believed that the authentic individual would choose the higher path as the clear and obvious one to follow (erasing the ambivalences and ambitendencies of unilevel conflicts). If the person’s actual behaviour subsequently falls short of the ideal, internal disharmony and a drive to review and reconstruct one’s life often follow. Multilevelness thus represents a new and powerful type of conflict, a conflict that is developmental in Dąbrowski’s approach.

Vertical conflicts are critical in leading to autonomy and advanced personality growth. If the person is to achieve higher levels, the shift to multilevelness must occur. If a person does not have the developmental potential to move into a multilevel view, then he or she will fall back from the crises of Level II to reintegrate at Level I. In the shift to multilevelness, the horizontal (unilevel), stimulus-response model of life is replaced by a vertical and hierarchical analysis. This vertical view becomes anchored by one’s emerging individual value structure, and all events are seen in relation to personal ideals. These personal value ideals become the personality ideal: how the person wants to live his or her life. As events in life are seen in relation to this multilevel, vertical view, it becomes impossible to support positions that favour the lower course when higher goals can be identified (or imagined).

Level IV: Directed Multilevel Disintegration

In Level IV the person takes full control of their development. The involuntary spontaneous development of Level III is replaced by a deliberate, conscious and self-directed review of life from the multilevel perspective. This level marks the real emergence of the third factor, described by Dąbrowski as an autonomous factor “of conscious choice (valuation) by which one affirms or rejects certain qualities in oneself and in one’s environment”. The person consciously reviews his or her existing belief system and tries to replace lower, automatic views and reactions with carefully thought out, examined and chosen ideals. These new values will increasingly be reflected in the person’s behaviour. Behaviour becomes less reactive, less automatic and more deliberate as behavioural choices fall under the influence of the person’s higher, chosen ideals.

Social mores are reviewed and re-accepted by a conscious internalisation when the individual feels it is appropriate. Likewise, when the person feels it is proper, a social value is reviewed and may be rejected to be replaced by a self-perceived higher alternative value. One’s social orientation comes to reflect a deep responsibility based on both intellectual and emotional factors. At the highest levels “individuals of this kind feel responsible for the realization of justice and for the protection of others against harm and injustice. Their feelings of responsibility extend almost to everything.”

This perspective results from seeing life in relation to one’s hierarchy of values (the multilevel view) and the subsequent appreciation of the potential of how life could be, and ought to be, lived. One’s disagreements with the (lower level) world are expressed compassionately in doing what one can to help achieve the “ought”.

Given their genuine (authentic) prosocial outlook, people achieving higher development also raise the level of their society. Prosocial here is not just support of the existing social order. If the social order is lower and you are adjusted to it, then you also reflect the lower (negative adjustment in Dąbrowski’s terms, a Level I feature). Here, prosocial is a genuine cultivation of social interactions based on higher values. These positions often conflict with the status quo of a lower society (positive maladjustment). In other words, to be maladjusted to a low-level society is a positive feature.

Level V: Secondary Integration

The fifth level displays an integrated and harmonious character, but one vastly different from that at the first level. At this highest level, one’s behaviour is guided by conscious, carefully weighed decisions based on an individualised and chosen hierarchy of personal values. Behaviour conforms to this inner standard of how life ought to be lived, and thus little inner conflict arises.

Level V is often marked by creative expression. Especially at Level V, problem solving and art represent the highest and noblest features of human life. Art captures the innermost emotional states and is based on a deep empathy and understanding of the subject. Often, human suffering and sacrifice are the subjects of these works. Truly visionary works, works that are unique and novel, are created by people expressing a vision unrestrained by convention. Advances in society, through politics, philosophy and religion, are therefore commonly associated with strong individual creativity or accomplishments.

Applications

Therapy

The theory of positive disintegration has an extremely broad scope and has implications for many areas. One central application applies to psychological and psychiatric diagnosis and treatment. Dąbrowski advocated a comprehensive, multidimensional diagnosis of the person’s situation, including symptoms and developmental potentials.

Symptoms and Developmental Potential

If the disintegration appears to fit into a developmental context, then the person is educated in the theory and encouraged to take a developmental view of his or her situation and experiences. Rather than being eliminated, symptoms are reframed to yield insight and understanding into life and the person’s unique situation.

The Importance of Narratives

Dąbrowski illustrated his theory through autobiographies of and biographies about those who have experienced positive disintegration. The gifted child, the suicidal teen or the troubled artist is often experiencing the features of TPD, and if they accept and understand the meaning of their intense feelings and crises, they can move ahead, not fall apart. The completion of an extensive autobiography to help the individual gain perspective on his or her past and present is an important component in the autopsychotherapy process. In this process, the therapist plays a very small role and acts more as an initial stimulus than an ongoing therapist. Dąbrowski asked clients to read his books and to see how his ideas might relate to their lives.

Autopsychotherapy

For Dąbrowski, the goal of therapy is to eliminate the therapist by providing a context within which a person can understand and help oneself, an approach to therapy that he called autopsychotherapy. The client is encouraged to embark on a journey of self-discovery with an emphasis on looking for the contrast between what is higher versus what is lower within his or her personality and value structure. The person is encouraged to further explore his or her value structure especially as it relates to the rationale and justification of positions. Discrepancies between values and behaviour are highlighted. The approach is called autopsychotherapy to emphasize the important role that the individual must play in his or her own therapy process and in the larger process of personality development. The individual must come to see that he or she is in charge of determining or creating his or her own unique personality ideal and value structure. This includes a critical review of social mores and values that have been learned.

Dąbrowski was very concerned about what he called one-sided development, in which people display significant advanced development in only one aspect of life, usually intellectual. He believed that it is crucial to balance one’s development.

Overexcitability

Dąbrowski also encouraged people to see their reactions (overexcitabilities) and their phenomenological view of the world in the context of their developmental potential. The experience of, and reaction to, crises are a very important aspect of this approach and people are encouraged to experience personal crises with a positive and developmental view.

Dąbrowski reminds clients that without internal disease there is little stimulus for change or growth. Rather than trying to rapidly ameliorate symptoms, this approach encourages individuals to fully experience their feelings and to try to maintain a positive and developmental orientation to what they may perceive as strong depression or anxiety. Of course, this is a unique approach in today’s world of seeking immediate and total relief of any unpleasant psychological experience (although it can be compared to Aron’s to some extent).

Dąbrowski and the Gifted Individual

In an appendix to Dąbrowski (1967), results of investigations done in 1962 with Polish youth are reported. Specifically, “a group of gifted children and young people aged 8 to 23” were examined (p.251). Of the 80 youth studied, 30 were “intellectually gifted” and 50 were from “drama, ballet, and plastic art schools” (p.251). Dąbrowski found that every one of the children displayed overexcitability, “which constituted the foundation for the emergence of neurotic and psychoneurotic sets. Moreover it turned out that these children also showed sets of nervousness, neurosis, and psychoneurosis of various kinds and intensities, from light vegetative symptoms, or anxiety symptoms, to distinctly and highly intensive psychasthenic or hysterical sets” (p.253). Dąbrowski asked why these children should display such “states of nervousness or psychoneurosis” and suggested that it was due to the presence of OE (p.255). “Probably the cause is more than average sensitivity which not only permits one to achieve outstanding results in learning and work, but at the same time increases the number of points sensitive to all experiences that may accelerate anomalous reactions revealing themselves in psychoneurotic sets” (p.255).

The association between OE and giftedness appears to be borne out in the research (Lysy and Piechowski 1983; Piechowski 1986; Piechowski and Miller 1995). It appears that at the least OE is a marker of potential for giftedness/creativity. Dąbrowski’s basic message is that the gifted will disproportionately display this process of positive disintegration and personality growth.

Key Ideas

The theory is based on key ideas that may be listed as follows:

  • That lower animal instincts (first factor) must be inhibited and transformed into “higher” forces for people to be Human (this ability to transform instincts is what separates people from other animals).
  • That the common initial personality integration, based upon socialisation (second factor), does not reflect true personality.
  • At the initial level of integration, there is little internal conflict as when one “goes along with the group”, there is little sense of individual wrongdoing. External conflicts often relate to the blockage of social goals – career frustrations for example. The social mores and values prevail with little question or conscious examination.
  • True personality must be based upon a system of values that are consciously and volitionally chosen by the person to reflect their own individual sense of “how life ought to be” and their “personality ideal” – the ideal person they feel they “ought to be”.
  • The lower animal instincts and the forces of peer groups and socialisation are inferior to the autonomous self (personality) constructed by the conscious person.
  • To break down the initial integration, crises and disintegrations are needed, usually provided by life experience.
  • These disintegrations are positive if the person can achieve positive and developmental solutions to the situation.
  • “Unilevel crises” are not developmental as the person can only choose between equal alternatives (go left or go right?).
  • A new type of perception involves “multilevelness”, a vertical view of life that compares lower versus higher alternatives and now allows the individual to choose a higher resolution to a crisis over other available, but lower, alternatives – the developmental solution.
  • “Positive disintegration” is a vital developmental process.
  • Dąbrowski developed the idea of “developmental potential” to describe the forces needed to achieve autonomous personality development.
  • Developmental potential includes several factors including innate abilities and talents, “overexcitability” and the “third factor”.
  • Overexcitability is a measure of an individual’s level of nervous response. Dąbrowski found that the exemplars he studied all displayed an overly sensitive nervous system, also making them prone to angst, depression and anxiety – psychoneuroses in Dąbrowski’s terms, a very positive and developmental feature.
  • The third factor is a measure of an individual’s drive toward autonomy.
  • Dąbrowski’s approach is very interesting philosophically as it is Platonic, reflecting the bias of Plato toward essence – an individual’s essence is a critical determinant of his or her developmental course in life. However, Dąbrowski also added a major existential aspect as well, what one depends upon the anxieties felt and on how one resolves the day to day challenges one faces. Essence must be realised through an existential and experiential process of development. The characterisation advanced by Kierkegaard of “Knights of faith” may be compared to Dąbrowski’s autonomous individual.
  • Reviewed the role of logic and reasoning in development and concludes that intellect alone does not fully help people know what to do in life. Incorporates Jean Piaget’s views of development into a broader scheme guided by emotion. Emotion (how one feels about something) is the more accurate guide to life’s major decisions.
  • When multilevel and autonomous development is achieved, a secondary integration is seen reflecting the mature personality state. The individual has no inner conflict; they are in internal harmony as their actions reflect their deeply felt hierarchy of values.
  • Rejected Abraham Maslow’s description of self-actualisation (Dąbrowski was a personal friend and correspondent of Maslow’s). Actualisation of an undifferentiated human self is not a developmental outcome in Dąbrowski’s terms. Dąbrowski applied a multilevel (vertical) approach to self and saw the need to become aware of and to inhibit and reject the lower instinctual aspects of the intrinsic human self (aspects that Maslow would have people “embrace without guilt”) and to actively choose and assemble higher elements into a new unique self. Dąbrowski would have people differentiate the initial self into higher and lower aspects and to reject the lower and actualise the higher in creating unique personalities.

Secondary Integration versus Self-Actualisation

People have often equated Maslow’s concept of self-actualisation with Dąbrowski’s level of secondary integration. There are some major differences between these two ideas. Fundamentally, Maslow described self-actualisation as a process where the self is accepted “as is”, so both higher and lower aspects of the self are actualised. Dąbrowski introduces the notion that although the lower aspects may initially be intrinsic to the self, as human beings we are able to become aware of their lower nature. People are able to develop self-awareness as to how they feel about these low levels – if they feel badly about behaving in these lower ways, then they are able to cognitively and volitionally decide to inhibit and eliminate these behaviours. In this way, the higher aspects of the self are actualized while the lower aspects are inhibited and, for Dąbrowski, this is what is unique about humans and sets people apart from other animals – no other animal is able to differentiate their lower instincts and therefore can not inhibit their animalistic impulses, an idea also expressed in Plessner’s eccentricity.

Controversy

Few psychological tests exist that measure Dąbrowskian constructs. The most widely known instrument is the Overexcitability Questionnaire – Two.

According to some, Dąbrowski was influenced by his Catholic upbringing and pursued a lifelong obsession with self-mutilation resulting in his semi-autobiographical 1937 work, Psychological Basis of Self Mutilation. It is claimed by Majorie Battaglia that his personal experience as a victim of medical torture by Nazis for several months as a member of the Polish resistance, being only one of the 38 surviving psychiatrists in Poland out of the 400 practicing at the beginning of World War II, almost definitely informed his world view.

What is the Myth of Mental Illness (Book)

Introduction

The Myth of Mental Illness 1961
The Myth of Mental Illness 1961.

The Myth of Mental Illness: Foundations of a Theory of Personal Conduct is a 1961 book by the psychiatrist Thomas Szasz, in which the author criticises psychiatry and argues against the concept of mental illness.

It received much publicity, and has become a classic, well known as an argument that “mentally ill” is a label which psychiatrists have used against people “disabled by living” rather than truly having a disease.

Refer to:

  • Game theory: For Szasz, mental illness is best understood through the lens of game theory
  • Neurodiversity: A belief of promoting the acceptance of numerous different brain types typically considered to be mental disorders or illnesses by the scientific community

Background

Szasz writes that he became interested in writing The Myth of Mental Illness in approximately 1950, when, having become established as a psychiatrist, he became convinced that the concept of mental illness was vague and unsatisfactory. He began work on the book in 1954, when he was relieved of the burdens of a full-time psychiatric practice by being called to active duty in the navy. Later in the 1950s, it was rejected by the first publisher to whom Szasz submitted the manuscript. Szasz next sent the manuscript to Paul Hoeber, director of the medical division of Harper & Brothers, who arranged for it to be published.

Summary

Szasz argues that it does not make sense to classify psychological problems as diseases or illnesses, and that speaking of “mental illness” involves a logical or conceptual error. In his view, the term “mental illness” is an inappropriate metaphor and there are no true illnesses of the mind. His position has been characterised as involving a rigid distinction between the physical and the mental.

The legitimacy of psychiatry is questioned by Szasz, who compares it to alchemy and astrology, and argues that it offends the values of autonomy and liberty. Szasz believes that the concept of mental illness is not only logically absurd but has harmful consequences: instead of treating cases of ethical or legal deviation as occasions when a person should be taught personal responsibility, attempts are made to “cure” the deviants, for example by giving them tranquilisers. Psychotherapy is regarded by Szasz as useful not to help people recover from illnesses, but to help them “learn about themselves, others, and life.” Discussing Jean-Martin Charcot and hysteria, Szasz argues that hysteria is an emotional problem and that Charcot’s patients were not really ill.

Reception

The Myth of Mental Illness received much publicity, quickly became a classic, and made Szasz a prominent figure. The book was reviewed in the American Journal of Psychiatry, Journal of Nervous and Mental Disease, Psychosomatic Medicine, Archives of General Psychiatry, Clinical Psychology Review, and Psychologies. Published at a vulnerable moment for psychiatry, when Freudian theorizing was just beginning to fall out of favour and the field was trying to become more medically oriented and empirically based, the book provided an intellectual foundation for mental patient advocates and anti-psychiatry activists. It became well known in the mental health professions and was favourably received by those sceptical of modern psychiatry, but placed Szasz in conflict with many doctors. Soon after The Myth of Mental Illness was published, the Commissioner of the New York State Department of Mental Hygiene demanded, in a letter citing the book, that Szasz be dismissed from his university position because he did not accept the concept of mental illness.

The philosopher Karl Popper, in a 1961 letter to Szasz, called the book admirable and fascinating, adding that, “It is a most important book, and it marks a real revolution.” The psychiatrist David Cooper wrote that The Myth of Mental Illness, like the psychiatrist R.D. Laing’s The Divided Self (1960), proved stimulating in the development of anti-psychiatry, though he noted that neither book is itself an anti-psychiatric work. He described Szasz’s work as “a decisive, carefully documented demystification of psychiatric diagnostic labelling in general.” Socialist author Peter Sedgwick, writing in 1982, commented that in The Myth of Mental Illness, Szasz expounded a “game-playing model of social interaction” which is “zestful and insightful” but “neither particularly uncommon nor particularly iconoclastic by the standards of recent social-psychological theorising.” Sedgwick argued that many of Szasz’s observations are valuable regardless of the validity of Szasz’s rejection of the concept of mental illness, and could easily be accepted by psychotherapists. Although agreeing with Szasz that the assignation of mental illness could undermine individual responsibility, he noted that this did not constitute an objection to the concept itself.

The philosopher Michael Ruse called Szasz the most forceful proponent of the thesis that mental illness is a myth. However, while sympathetic to Szasz, he considered his case over-stated. Ruse criticized Szasz’s arguments on several grounds, maintaining that while the concepts of disease and illness were originally applied only to the physiological realm, they can properly be extended to the mind, and there is no logical absurdity involved in doing so. Kenneth Lewes wrote that The Myth of Mental Illness is the most notable example of the “critique of the institutions of psychiatry and psychoanalysis” that occurred as part of the “general upheaval of values in the 1960s”, though he saw the work as less profound than Michel Foucault’s Madness and Civilization (1961).

The psychiatrist Peter Breggin called The Myth of Mental Illness a seminal work. The author Richard Webster described the book as a well known argument against the tendency of psychiatrists to label people who are “disabled by living” as mentally ill. He observed that while some of Szasz’s arguments are similar to his, he disagreed with Szasz’s view that hysteria was an emotional problem and that Charcot’s patients were not genuinely mentally ill. The lawyer Linda Hirshman wrote that while few psychiatrists adopted the views Szasz expounded in The Myth of Mental Illness, the book helped to encourage a revision of their diagnostic and therapeutic claims. The historian Lillian Faderman called the book the most notable attack on psychiatry published in the 1960s, adding that “Szasz’s insights and critiques would prove invaluable to the homophile movement.”

What is Repression (Psychoanalysis)?

Introduction

Repression is a key concept of psychoanalysis, where it is understood as a defence mechanism that “ensures that what is unacceptable to the conscious mind, and would if recalled arouse anxiety, is prevented from entering into it.”

According to psychoanalytic theory, repression plays a major role in many mental illnesses, and in the psyche of the average person.

There has been debate as to whether (or how often) memory repression really occurs and mainstream psychology holds that true memory repression occurs only very rarely. American psychologists began to attempt to study repression in the experimental laboratory around 1930. However, psychoanalysts were at first uninterested in attempts to study repression in laboratory settings, and later came to reject them. Most psychoanalysts concluded that such attempts misrepresented the psychoanalytic concept of repression.

Sigmund Freud’s Theory

As Sigmund Freud moved away from hypnosis, and towards urging his patients to remember the past in a conscious state, ‘the very difficulty and laboriousness of the process led Freud to a crucial insight’. The intensity of his struggles to get his patients to recall past memories led him to conclude that ‘there was some force that prevented them from becoming conscious and compelled them to remain unconscious … pushed the pathogenetic experiences in question out of consciousness. I gave the name of repression to this hypothetical process’.

Freud would later call the theory of repression “the corner-stone on which the whole structure of psychoanalysis rests” (“On the History of the Psycho-Analytic Movement”).

Freud developed many of his early concepts with his mentor, Josef Breuer. Moreover, while Freud himself noted that the philosopher Arthur Schopenhauer in 1884 had hinted at a notion of repression (but he had only read him in later life), he did not mention that Johann Friedrich Herbart, psychologist and founder of pedagogy whose ideas were very influential in Freud’s environment and in particular with Freud’s psychiatry teacher Theodor Meynert, had used the term in 1824 in his discussion of unconscious ideas competing to get into consciousness.

Stages

Freud considered that there was ‘reason to assume that there is a primal repression, a first phase of repression, which consists in the psychical (ideational) representative of the instinct being denied entrance into the conscious’, as well as a ‘second stage of repression, repression proper, which affects mental derivatives of the repressed representative: distinguished what he called a first stage of ‘primal repression’ from ‘the case of repression proper (“after-pressure”).’

In the primary repression phase, ‘it is highly probable that the immediate precipitating causes of primal repressions are quantitative factors such as … the earliest outbreaks of anxiety, which are of a very intense kind’. The child realises that acting on some desires may bring anxiety. This anxiety leads to repression of the desire.

When it is internalised, the threat of punishment related to this form of anxiety becomes the superego, which intercedes against the desires of the id (which works on the basis of the pleasure principle). Freud speculated that ‘it is perhaps the emergence of the super-ego which provides the line of demarcation between primal repression and after-pressure

Therapy

Abnormal repression, as defined by Freud, or neurotic behaviour occurs when repression develops under the influence of the superego and the internalised feelings of anxiety, in ways leading to behaviour that is illogical, self-destructive, or antisocial.

A psychotherapist may try to ameliorate this behaviour by revealing and reintroducing the repressed aspects of the patient’s mental processes to their conscious awareness – ‘assuming the role of mediator and peacemaker … to lift the repression’. In favourable circumstances, ‘Repression is replaced by a condemning judgement carried out along the best lines’, thereby reducing anxiety over the impulses involved.

Reactions

The philosopher Jean-Paul Sartre challenged Freud’s theory by maintaining that there is no “mechanism” that represses unwanted thoughts. Since “all consciousness is conscious of itself” we will be aware of the process of repression, even if skilfully dodging an issue. The philosopher Thomas Baldwin stated in The Oxford Companion to Philosophy (1995) that Sartre’s argument that Freud’s theory of repression is internally flawed is based on a misunderstanding of Freud. The philosopher Roger Scruton argued in Sexual Desire (1986) that Freud’s theory of repression disproves the claim, made by Karl Popper and Ernest Nagel, that Freudian theory implies no testable observation and therefore does not have genuine predictive power, since the theory has “strong empirical content” and implies testable consequences.

Later Developments

The psychoanalyst Otto Fenichel stressed that ‘if the disappearance of the original aim from consciousness is called repression, every sublimation is a repression (a “successful” one: through the new type of discharge, the old one has become superfluous)’.

The psychoanalyst Jacques Lacan stressed the role of the signifier in repression – ‘the primal repressed is a signifier’ – examining how the symptom is ‘constituted on the basis of primal repression, of the fall, of the Unterdrückung, of the binary signifier … the necessary fall of this first signifier’.

Family therapy has explored how familial taboos lead to ‘this screening-off that Freud called “repression”‘, emphasising the way that ‘keeping part of ourselves out of our awareness is a very active process … a deliberate hiding of some feeling from our family’.

Experimental Attempts to Study Repression

According to the psychologist Donald W. MacKinnon and his co-author William F. Dukes, American psychologists began to attempt to study repression in the experimental laboratory around 1930. These psychologists were influenced by an exposition of the concept of repression published by the psychoanalyst Ernest Jones in the American Journal of Psychology in 1911. Like other psychologists who attempted to submit the claims of psychoanalysis to experimental test, they did not immediately try to develop new techniques for that purpose, instead conducting surveys of the psychological literature to see whether “experiments undertaken to test other theoretical assertions” had produced results relevant to assessing psychoanalysis. In 1930, H. Meltzer published a survey of experimental literature on “the relationships between feeling and memory” in an attempt to determine the relevance of laboratory findings to “that aspect of the theory of repression which posits a relationship between hedonic tone and conscious memory.” However, according to MacKinnon and Dukes, because Meltzer had an inadequate grasp of psychoanalytic writing he misinterpreted Freud’s view that the purpose of repression is to avoid “unpleasure”, taking the term to mean simply something unpleasant, whereas for Freud it actually meant deep-rooted anxiety. Nevertheless, Meltzer pointed out shortcomings in the studies he reviewed, and in MacKinnon and Dukes’s view he also “recognized that most of the investigations which he reviewed had not been designed specifically to test the Freudian theory of repression.”

In 1934, the psychologist Saul Rosenzweig and his co-author G. Mason criticized Meltzer, concluding that the studies he reviewed suffered from two basic problems: that the studies “worked with hedonic tone associated with sensory stimuli unrelated to the theory of repression rather than with conative hedonic tone associated with frustrated striving, which is the only kind of ‘unpleasantnesss’ which, according to the Freudian theory, leads to repression” and that they “failed to develop under laboratory control the experiences which are subsequently to be tested for recall”. In MacKinnon and Dukes’s view, psychologists who wanted to study repression in the laboratory “faced the necessity of becoming clear about the details of the psychoanalytic formulation of repression if their researches were to be adequate tests of the theory” but soon discovered that “to grasp clearly even a single psychoanalytic concept was an almost insurmountable task.” MacKinnon and Dukes attribute this situation to the way in which Freud repeatedly modified his theory “without ever stating clearly just which of his earlier formulations were to be completely discarded, or if not discarded, how they were to be understood in the light of his more recent assertions.”

MacKinnon and Dukes write that, while psychoanalysts were at first only disinterested in attempts to study repression in laboratory settings, they later came to reject them. They comment that while

“the psychologists had criticized each other’s researches largely on the grounds that their experimental techniques and laboratory controls had not been fully adequate, the psychoanalysts rejected them on the more sweeping grounds that whatever else these researches might be they simply were not investigations of repression.”

They relate that in 1934, when Freud was sent reprints of Rosenzweig’s attempts to study repression, he responded with a dismissive letter stating that “the wealth of reliable observations” on which psychoanalytic assertions were based made them “independent of experimental verification.” In the same letter, Freud concluded that Rosenzweig’s studies “can do no harm.” MacKinnon and Dukes describe Freud’s conclusion as a “first rather casual opinion”, and state that most psychoanalysts eventually adopted a contrary view, becoming convinced that “such studies could indeed be harmful since they misrepresented what psychoanalysts conceived repression to be.”

Writing in 1962, MacKinnon and Dukes state that experimental studies “conducted during the last decade” have largely abandoned the term “repression”, choosing instead to refer to the phenomenon as “perceptual defence”. They argue that this change of terminology has had a major effect on how the phenomenon is understood, and that psychoanalysts, who had attacked earlier studies of repression, did not criticise studies of perceptual defence in a similar fashion, instead neglecting them. They concluded by noting that psychologists remained divided in their view of repression, some regarding it as well-established, others as needing further evidence to support it, and still others finding it indefensible.

A 2020 meta-analysis of 25 studies examined the evidence that active memory suppression actually leads to decreased memory. It was found that in people with a repressive coping strategy, the wilful avoidance of remembering certain memory contents leads to a significant reduction in memory performance for these contents. In addition, healthy people were better able to do this than anxious or depressed people. These results indicate that forgetting induced by suppression is a hallmark of mental wellbeing.

Repressed Memories

One of the issues Freud struggled with was the status of the childhood “memories” recovered from repression in his therapy. He concluded that “these scenes from infancy are not always true. Indeed, they are not true in the majority of cases, and in a few of them they are the direct opposite of the historical truth”. Controversy arose in the late 20th century about the status of such “recovered memories”, particularly of child abuse, with many claiming that Freud had been wrong to ignore the reality of such recovered memories.

While accepting “the realities of child abuse”, the feminist Elaine Showalter considered it important that one “distinguishes between abuse remembered all along, abuse spontaneously remembered, abuse recovered in therapy, and abuse suggested in therapy”. Memory researcher Elizabeth Loftus has shown that it is possible to implant false memories in individuals and that it is possible to “come to doubt the validity of therapeutically recovered memories of sexual abuse … [as] confabulations”. However, criminal prosecutors continue to present them as evidence in legal cases.

There is debate about the possibility of the repression of psychological trauma. While some evidence suggests that “adults who have been through overwhelming trauma can suffer a psychic numbing, blocking out memory of or feeling about the catastrophe”, it appears that the trauma more often strengthens memories due to heightened emotional or physical sensations (However these sensations may also cause distortions, as human memory in general is filtered both by layers of perception, and by “appropriate mental schema … spatio-temporal schemata”).

What is a Mental Health Consumer?

Introduction

A mental health consumer (or mental health patient) is a person who is obtaining treatment or support for a mental disorder, also known as psychiatric or mental illness.

The term was coined by people who use mental health services in an attempt to empower those with mental health issues, historically considered a marginalised segment of society. The term suggests that there is a reciprocal contract between those who provide a service and those who use a service and that individuals have a choice in their treatment and that without them there could not exist mental health providers.

Brief History

In the 1970s the term “patient” was most commonly used. Mental Health activists of the civil rights times recognised, as did many other groups seeking self-definition, that such labels are metaphors that reflect how identities are perceived and constructed. In particular, in the mental health field they shape the nature of the relationship between the giver and receiver of psychiatric services, be it one with an emphasis on reciprocity or hierarchy. Users of psychiatric services repulsed the efforts of experts to define them and sought to develop ways to define themselves. In Australia, informal support groups of people who had recovered from episodes of mental ill health were formed during the first wave of moving patients out of psychiatric hospitals into the community in the 1960s. In the USA and other countries, radical movements to change service delivery and legislation began to be driven by consumers during the 1980s. Activists, such as Judi Chamberlain, pressed for alternatives to psychiatrist dominated and controlled systems of mental health provision. Chamberlain’s On Our Own: Patient Controlled Alternatives to the Mental Health System helped guide others intent on a more collaborative form of mental health healing.

In the 1980s with some funding from NIMH, small experimental groups flourished. In 1985 at the First Alternatives Conference attendees agreed upon the term “consumer” reflecting the patients’ choice of services. The term also implied assumptions of rationality and ability to make choices in one’s own best interests rather than be a passive incapacitated recipient of “expert” attention. In the 1990s many consumer groups were formed, such as Self Help Clearing House and the National Empowerment Centre. They continued to press for more peer involvement in alternatives treatments, pointing out that peers support and comfort, which may be in contrast to some therapists who just attempt to change the behaviour and thinking patterns.

Contemporary Usage

Today, the word mental health consumer has expanded in the popular usage of consumers themselves to include anyone who has received mental health services in the past, anyone who has a behavioural health diagnosis, or simply anyone who has experienced a mental or behavioural disorder. Other terms sometimes used by members of this community for empowerment through positive self-identification include “peers,” “people with mental health disabilities,” “psychiatric survivors,” “users,” individuals with “lived experience” and “ex-patients.” The term “service users,” is commonly used in the UK. In the US “consumer” is most frequently used by ex-patients and users of psychiatric and alternative services.

One can view this term, “consumer,” neutrally as a person who receives psychological services, perhaps from a psychologist, a psychiatrist or a social worker. It can be impersonal term relating to the use in the health sector of a large economy. It suggests that the consumer expects to have some influence on service delivery and provides feedback to the provider. Used in its more activist sense, consumer groups aim to correct perceived problems in mental health services and to promote consultation with consumers. Consumer theory was devised to interpret the special relationship between a service provider and service user in the context of mental health. Consumer theory examines the consequences and sociological meaning of the relationship.

What was the Icarus Project?

Introduction

The Icarus Project was a media and activist endeavour broadly aligned to the anti-psychiatry movement and recovery approach, arguing that mental illness should be understood as an issue of social justice and that a person’s mental state can improve through greater social support and collective liberation.

It shares similarities with the academic fields of Psychopolitics and Mad Studies. The name is derived from Icarus, a hero in Greek mythology, and is metaphorically used to convey that the experiences of mental distress and other extreme mental states can lead to “potential[ly] flying dangerously close to the sun.”

Brief History

In 2002, musician Sascha Altman DuBrul wrote “Bipolar World”, an article published in the San Francisco Bay Guardian. The article described his experiences being diagnosed with bipolar disorder. Among the dozens of e-mails and other correspondence that he received after this publication was a letter from Ashley McNamara, now known as Jacks, an artist and writer who identified strongly with DuBrul’s experiences. DuBrul and McNamara corresponded for a few weeks before finally meeting in person and deciding to start The Icarus Project. Years later, musician-activist Bonfire Madigan Shive and counsellor/activist Will Hall became a key leader in The Icarus Project’s administration and development.

In the Journal of Medical Humanities, co-founder DuBrul wrote of The Icarus Project:

Though we did not fully understand it in the early days, we were walking in the footsteps of a large body of knowledge and thought from the 1960s, grouped under the category of Anti-Psychiatry.

He also noted the group and its members were inspired by a range of social trends and schools of thought including anarchism, permaculture/sustainable ecology, LGBTQ rights, harm reduction, global justice movement, the Beat Generation, counterculture, and punk rock. He writes, “Our response to the label ‘bipolar’ was not a ‘normal’ response, which is why the Icarus Project brought a new perspective to psychic diversity. To create this perspective, we drew inspiration from many social movements and subcultural communities that came before us. So even though our response was unusual, it did not arise in a vacuum. In creating the Icarus Project, we wove together the ideas and practices in these movements to imagine a powerful new counter narrative to the dominant mental health narrative that went beyond a questioning of the language around ‘bipolar’ and critiqued the system itself.”

The first step, they decided, was creating a website where people who identified with “bipolar and other ‘mental illness’ [could] find real community and contribute to it.” DuBrul states that by 2003, “The Icarus Project website was up and running, and a virtual community began to evolve around the discussion forums.” He notes that user-generated content online enabled The Icarus Project’s growth: “We were attracting interesting people, creating discussion forums with names like ‘Alternate Dimensions or Psychotic Delusions’ and ‘Experiencing Madness and Extreme States.’ There was no place else where people who used psych meds and people who did not, people who identified with diagnostic categories and people who did not, could all talk with each other and share stories. Because of the outreach in the anarchist and activist community, there was a high percentage of creative people with a radical political analysis. And with the (seeming) anonymity of the Internet, people felt comfortable being honest and sharing intimate stories about their lives. Our website served as a refuge for a diverse group of people who were learning the ways in which new narratives could be woven about their lives.”

Mission

The Icarus Project’s stated aims are to provide a “support network and education project by and for people who experience the world in ways that are often diagnosed as mental illness.” The national Icarus Collective staff is set up to support local groups instead of creating the smaller organisations themselves. The responsibilities of the local group are to gather people locally for support, education, activism, and access to alternatives to mainstream medical diagnosis and treatment. The Project advocates self-determination and caution when approaching psychiatric care. It encourages harm reduction, alternatives to the prevailing medical model that is accepted by the vast majority of mental health professionals, and self-determination in treatment and diagnosis. Key members of The Icarus Project state that they “envision a world with more options to navigate mental health issues: options that support self-determination, centre people who are most impacted by mental health-based oppression, and most critically, uplift social transformation as central to individual wellbeing.”

In 2005, Journalist Jennifer Itzenson noted that the Icarus Project accepts those with a wide range of perspectives on mental health issues, but also describes “an edge of militancy within the group,” particularly among those who reject medication. Itzenson also writes that while medical professionals applaud groups like the Icarus Project for providing a sense of support and community, and combating social stigmas related to bipolar and other mental health issues, the group’s questioning of the medical paradigm is “misguided” and that rejecting medication is a “potentially fatal choice” for those with bipolar disorder. A Newsweek article provides the following perspective on The Icarus Project’s stance towards medication: “While some critics might view Icaristas as irresponsible, their skepticism about drugs isn’t entirely unfounded. Lately, a number of antipsychotic drugs have been found to cause some troubling side effects.”

Writer Mark Lukach describes in an article for Pacific Standard his experience asking co-founder Sascha Altman DuBrul about the role of psychiatric medication as a part of his wife’s recovery from a bipolar diagnosis. Lukach articulates The Icarus Project’s approach to self-determination in psychiatric treatment. Lukach wrote:

“As for medication, DuBrul said that he believed that the answer to the question of whether or not to use pharmaceuticals needed to be far more nuanced than yes or no. The best response might be maybe, sometimes, or only certain medications. For instance, DuBrul shared that he takes lithium every night because he’s confident that, after four hospitalizations and over a decade with the label bipolar, the medication is a positive part of his care. Not the whole solution, but a piece.”

Anthropologist Erica Hua Fletcher describes Icarus Project member’s diverse ways of discussing altered mental states in the Journal of Medical Humanities. Fletcher writes:

While many Icarus contributors have found relief through the use of psycho-pharmaceutical interventions and other bio-psychiatric technologies, they also have experienced the limitations of medical paradigms and language to recognize the fullness of their lives. Because of this, they frequently adopt alternative words and phrases beyond bio-psychiatric terms to describe their mental states such as “neurodivergent processing,” “diasporas of distressing symptoms,” “sensory/cognitive/emotional trauma,” or “cognitive-emotional terror.” “Bipolar disorder” is interchangeable with highs and lows; “psychosis” can be seen as a reckoning; and nonconsensus realities can describe extreme experiences, which psychiatrists could label as symptoms of “schizophrenia” (such as hearing voices others do not hear or seeing objects others do not see). Such alternative words and phrases do not diminish the utility of bio- psychiatric terminology nor do they directly undermine medical treatment options, yet they allow for a range of descriptors and call for attention to individual needs and desires. They call us to listen to personal stories, to forces at work within communities, and to reevaluate the languages that enframe mental illness as such.” She goes on to state, “Alternative language beyond the biomedical paradigm of mental illness fosters a diversity of paradigms. Moreover, it can create a reflective space for those with mental suffering (and for their healthcare providers) to see themselves outside of a medical identity, reevaluate their self-care regimens, advocate for the care they would like to receive, and connect to others who may have similar concerns about ascribing to solely psycho-pharmaceutical interventions.”

As of early 2018, Icarus Project staff describe their expertise in social activism, herbalism, and labour organising; none is a licensed medical or mental health professional. Icarus Project advisory board members describe themselves as educators, artists, activists, writers, healers, community organisers, and other creative types and some identify as Latinx, queer, trans, people of colour or mixed race, and trauma survivors; none is a licensed medical or mental health professional. Leadership currently offers publications on self-care and community care, workshops and training for peers, training and talks for providers, peer support spaces, webinars, and other events.

Structure/Funding

The Icarus Project is currently under the fiscal sponsorship of FJC, a non-profit 501(c)3 umbrella organization arm of an investment firm, based in New York City. The Icarus Project currently gets the bulk of its money from foundation grants, including the Ittleson Foundation, but it also has many individual donors.

The Icarus Project Network

Places where local chapters met included Anchorage, Alaska; Asheville, North Carolina; Atlanta, Georgia; Boston, Massachusetts; Conway, Arkansas; Chicago, Illinois; Los Angeles, California (Wildflowers’ Movement); Minneapolis, Minnesota; Madison, Wisconsin; New York City, New York; Northampton, Massachusetts (Freedom Centre); Philadelphia, Pennsylvania; Portland, Oregon; San Francisco (Bay Area), California; Columbus, Ohio; Gainesville, Florida.

Media Mentions

The Icarus Project has been mentioned in passing in The New York Times as a resource for those who “don’t want to ‘get better'”, by Frontline 20/20, and many local media outlets.

Publications

Educational materials published by The Icarus Project have been published in Spanish, German, French, Italian, Japanese, Greek, and Bosnian/Croatian. Some of these publications are listed below:

  • In March 2004, The Icarus Project released Navigating the Space Between Brilliance and Madness; A Reader and Roadmap of Bipolar Worlds. The book is currently in its 6th printing.
  • In July 2006, The Icarus Project released the first draft of Friends Make the Best Medicine: A Guide to Creating Community Mental Health Support Networks.
  • In 2008, The Icarus Project released Through the Labyrinth; A Harm Reduction Guide to Coming Off Psychiatric Drugs, and in 2009 this publication was translated into Spanish and German and made available for free download on the Icarus Project website.
  • In 2012, The Icarus Project released Mindful Occupation: Rising Up without Burning Out.
  • In 2015, The Icarus Project released Madness and Oppression: Personal Paths to Transformation and Collective Liberation.

Filmography

Films about Icarus Project members are listed below:

  • Ken Paul Rosenthal (2010). Crooked Beauty. 30 min. Poetic documentary featuring Jacks McNamara. In Mad Dance Mental Health Film Trilogy.
  • Ken Paul Rosenthal (2018). Whisper Rapture. 36 min. A doc-opera featuring Bonfire Madigan Shive.

What is Partial Hospitalisation?

Introduction

Partial hospitalisation, also known as PHP (partial hospitalisation programme), is a type of programme used to treat mental illness and substance abuse. In partial hospitalisation, the patient continues to reside at home, but commutes to a treatment centre up to seven days a week. Partial hospitalisation focuses on the overall treatment of the individual and is intended to avert or reduce in-patient hospitalisation.

The pioneer of partial hospital programmes, Dr. Albert E. Moll, believed that some patients would be unable to be away from their families or from work and that these programmes would reduce the cost of long-term care.

Partial hospitalisation programmes in the United States can be provided in either a hospital setting or by a free-standing community mental health centre (CMHC).

Treatment during a typical day may include group therapy, psych-educational groups, skill building, individual therapy, and psychopharmacological assessments and check-ins.

Programmes:

  • Are available for the treatment of alcoholism and substance abuse problems, Alzheimer’s disease, anorexia and bulimia, depression, bipolar disorder, anxiety disorders, schizophrenia, and other mental illnesses.
  • Geared specifically toward geriatric patients, adult patients, adolescents, or young children also exist.
  • For adolescents and children usually include an academic programme, to either take the place of or to work with the child’s local school.

Funding

Service providers in the United States are funded by private insurance as part of a designated continuum of care as well as Medicare and, for some states, Medicaid.

Currently, many providers are moving the partial hospitalisation model of day treatment toward more acute short-term services. Hospitals and community mental health organisations are using PHP’s to handle acutely ill persons who are able to better understand their illness, become adjusted to medication regimes, develop important coping skills, and set recovery goals that enable them to function effectively as recovered individuals in the society.

Most programs are required to pass comprehensive reviews from national, state, and insurance bodies. Specific guidelines for assessment, treatment, facility maintenance, performance improvement, and client outcome studies are integral to partial hospitalisation programmes. The Association of Ambulatory Behavioural Health is the premier national group providing Standards and Guidelines, recently completed in 2015.

What is Alloplastic Adaptation?

Introduction

Alloplastic adaptation (from the Greek word “allos”, meaning “other”) is a form of adaptation where the subject attempts to change the environment when faced with a difficult situation. Criminality, mental illness, and activism can all be classified as categories of alloplastic adaptation.

The concept of alloplastic adaptation was developed by Sigmund Freud, Sándor Ferenczi, and Franz Alexander. They proposed that when an individual was presented with a stressful situation, they could react in one of two ways:

  • Autoplastic adaptation: The subject tries to change themselves, i.e. the internal environment.
  • Alloplastic adaptation: The subject tries to change the situation, i.e. the external environment.

Origins and Development

These terms are possibly due to Ferenczi, who used them in a paper on “The Phenomenon of Hysterical Materialization” (1919,24). But he there appears to attribute them to Freud (who may have used them previously in private correspondence or conversation). Ferenczi linked the purely “autoplastic” tricks of the hysteric…[to] the bodily performances of “artists” and actors.

Freud’s only public use of the terms was in his paper “The Loss of Reality in Neurosis and Psychosis” (1924), where he points out that “expedient, normal behaviour leads to work being carried out on the external world; it does not stop, as in psychosis, at effecting internal changes. It is no longer autoplastic but alloplastic”.

A few years later, in his paper on “The Neurotic Character” (1930), Alexander described “a type of neurosis in which…the patient’s entire life consists of actions not adapted to reality but rather aimed at relieving unconscious tensions”. Alexander considered that “neurotic characters of this type are more easily accessible to psychoanalysis than patients with symptom neuroses…[due] to the fact that in the latter the patient has regressed from alloplasticity to autoplasticity; after successful analysis he must pluck up courage to take action in real life”.

Otto Fenichel however took issue with Alexander on this point, maintaining that “The pseudo-alloplastic attitude of the neurotic character cannot be changed into a healthy alloplastic one except by first being transformed, for a time, into a neurotic autoplastic attitude, which can then be treated like an ordinary symptom neurosis”.

Human Evolution

Alloplasticity has also been used to describe humanity’s cultural “evolution”. Man’s “evolution by culture…is through alloplastic experiment with objects outside his own body….Unlike autoplastic experiments, alloplastic ones are both replicable and reversible”.

In particular, “advanced technological societies…are generally characterized by “alloplastic” relations with the environment, involving the manipulation of the environment itself”.

What is SANE (Charity)?

Introduction

SANE is a UK mental health charity working to improve quality of life for people affected by mental illness.

Brief History

SANE was established in 1986 to improve the quality of life for people affected by mental illness, following the overwhelming public response to a series of articles published in The Times entitled “The Forgotten Illness”. Written by the charity’s founder and Chief Executive, Marjorie Wallace, the articles exposed the neglect of people suffering from mental illness and the poverty of services and information for individuals and families. From its initial focus on schizophrenia (the name started as an acronym for “Schizophrenia: A National Emergency”), SANE expanded and is now concerned with all mental illnesses. SANE’s vision has been to raise public awareness, instigate research, and bring more effective professional treatment and compassionate care to everyone affected by mental illness.

During the COVID-19 pandemic lockdowns, SANE’s hotline received a 200% increase in calls.

Aims and Outcomes

SANE uses the Charities Evaluation Services framework to assess its work. They have three organisational aims:

  • Reducing the impact of mental illness.
  • Improving treatment and care by increasing knowledge about mental illness.
  • Influencing policy and public attitudes by increasing understanding of mental illness.

These aims are connected to a number of specific outcomes which are used to monitor and evaluate SANE’s work.

Objectives

SANE works to:

  • Raise awareness and combat stigma about mental illness, educating and campaigning to improve mental health services.
  • Provide care and emotional support for people with mental health problems, their families and carers as well as information for other organisations and the public.
  • Initiate research into the causes and treatments of serious mental illness such as schizophrenia and depression and the psychological and social impact of mental illness.

Online Forum

One of the many features of SANE’s website is the Support Forum – a peer to peer community, moderated by SANE. The Support Forum provides a space where people affected by mental illness, family, friends and carers can offer and receive mutual support at any time of day or night 365 days a year. Users of the Support Forum share thoughts, feelings and experiences of the difficulties and challenges that can arise from living with mental illness. The forum has several different discussion rooms including:

  • Newbies.
  • Family, Friends and Carers.
  • Information Exchange.
  • Creative Corner.
  • Rant Room.

Marie talked about her experience of using the Support Forum: “I was scared to tell anyone how I was feeling, so I used the Support Forum at first. There I found a community of other sufferers and realised I wasn’t alone. I can’t express how pleased I was – I had felt so isolated up until that point.”

Emotional Support

SANE offers emotional support and information to anyone affected by mental health problems through helpline (SANEline) and text (Textcare) services and an online Support Forum where people share their feelings and experiences.

These services are led by SANE’s team of mental health professionals and delivered by a force of over 140 volunteers who undergo rigorous training and in many cases give hundreds of hours of their free time each year. SANE’s Caller Care programme provides call-back to give on-going support and help people alleviate a crisis phase or get through difficult circumstances.

Research

SANE undertakes neuroscience research to understand the causes of serious mental illness. SANE opened the Prince of Wales International Centre (POWIC) for SANE Research in 2003 to focus this work and establish a home for multi-disciplinary research. SANE provides space within POWIC to the Oxford Mindfulness Centre, which provides Mindfulness-based cognitive therapy training, integrating brain research with meditation techniques, and Professor Daniel Freeman.

SANE’s psychosocial research team focuses on the social and psychological aspects of mental illness impacting service users, carers and mental health professionals.

Campaigns

SANE campaigns to influence mental health policy and improve services, as well as combating the stigma and ignorance, which all too often exacerbate the distress that people experience. Previous work includes; campaigning for reform of mental health law, campaigning for better access to psychological therapies and campaigning about the unacceptable standard of care on many psychiatric wards.

Black Dog Campaign

In 2011, to mark its 25th anniversary, SANE launched the Black Dog Campaign. The campaign aimed to increase awareness and understanding of depression and other mental illness, to introduce new emotional support services, and encourage more people to seek help.

The Black Dog has been used as a metaphor for depression from antiquity to the present day. To bring the campaign to life SANE designed Black Dog statues that were placed across London and other major UK cities to raise awareness, reduce stigma and misunderstanding of mental health problems and to encourage more people to seek help.

It was hoped that the physical presence of a Black Dog would help people define their experience of the “invisible” condition that characterises mental illness, as well as promoting more open discussion, understanding and acceptance. In order to deliver a positive message of support each of the black dogs had a “collar of hope” and all of them wore coats designed by celebrities, artists or members of the public.

Celebrity Support

SANE have a distinguished group of high-profile patrons. Over the years they have lent their time and energy to publicising services, backing campaigns and fundraising for continued growth and success of the charity.

Celebrity supporters include:

  • Ruby Wax.
  • Bradley Walsh.
  • Rory Bremner.
  • Ian Hislop.
  • James Arthur.
  • Joanna Lumley.
  • Michael Palin.
  • Trevor Phillips.
  • Adam Ant.

What is the California Mental Health Services Act (2005)?

Introduction

On November 2004, voters in the US state of California passed Proposition 63, the Mental Health Services Act (MHSA), which has been designed to expand and transform California’s county mental health service systems.

The MHSA is funded by imposing an additional one percent (1%) tax on individual, but not corporate, taxable income in excess of one million dollars. In becoming law on January 2005, the MHSA represents the latest in a Californian legislative movement, begun in the 1990s, to provide better coordinated and more comprehensive care to those with serious mental illness, particularly in underserved populations. Its claim of successes thus far, such as with the development of innovative and integrated Full Service Partnerships (FSPs), are not without detractors who highlight many problems but especially a lack of oversight, large amount of unspent funds, poor transparency, lack of engagement in some communities, and a lack of adherence to required reporting as challenges MHSA implementation must overcome to fulfil the law’s widely touted potential.

Background

At one time, California was known for having a strong mental health system. Treatment was available for Medi-Cal recipients with few limitations on care. Legislators and voters have acknowledged the inadequacy of California’s historically underfunded mental health system to care for the state’s residents, especially those with serious mental illness, over the past few decades. In 1991, to build a more community- and county-based system of care, the California legislature instituted realignment, a delegation of the control over mental health funds and care delivery from state to county. This was followed by a succession of legislation targeted towards marginalised populations with high documented rates of mental illness, such as the homeless (AB 2034, in 1999) and the potentially violent mentally ill (Laura’s Law, in 2002). However, with the passage of Proposition 63 in 2004, California voters acted upon a widespread perception that state and county mental health systems were still in disrepair, underfunded, and requiring a systematic, organizational overhaul. This perception echoed a nationwide perspective, with the President’s New Freedom Commission on Mental Health in 2003 calling for fundamental transformation of the historically fragmented mental health system. The MHSA is California’s attempt to lead the way in accomplishing such systemic reform.

In the end, voter consciences were pricked by the well-organised and -funded campaign that displayed both the need (50,000 mentally ill homeless people, according to the National Alliance on Mental Illness) and the promise (successes of past mental health initiatives) of increased funding for the mental health system. Then-Assemblyman Darrell Steinberg and Rusty Selix, executive director of the Mental Health Association in California, led the initiative by collecting at minimum 373,816 signatures, along with financial ($4.3 million) and vocal support from stakeholders. Though Governor Arnold Schwarzenegger and the business community were opposed to Proposition 63 because of the tax it would impose on millionaires, the opposition raised only $17,500. On 02 November 2004, Proposition 63 passed with 53.8% of the vote, with 6,183,119 voting for and 5,330,052 voting against the bill.

Overview

The voter-approved MHSA initiative provides for developing, through an extensive stakeholder process, a comprehensive approach to providing community based mental health services and supports for California residents. Approximately 51,000 taxpayers in California will be helping to fund the MHSA through an estimated $750 million in tax revenue during fiscal year 2005-2006.

The MHSA was an unprecedented piece of legislation in California for several reasons:

  • Its funding source, quantity, and allocation is dedicated for mental health services, including times of budget cuts to many other public programmes
  • It was intended to engage communities in prioritising which service elements would be funded.
  • It was focused on developing preventive and innovative programmes to help transform the mental health care system in California.

To accomplish its objectives, the MHSA applies a specific portion of its funds to each of six system-building components:

  • Community programme planning and administration (10%).
  • Community services and supports (45%).
  • Capital (buildings) and information technology (IT) (10%).
  • Education and training (human resources) (10%).
  • Prevention and early intervention (20%).
  • Innovation (5%).

Notably, none of the funds were to be used for programmes with existing fund allocations, unless it was for a new element or expansion in those existing programmes. 51% of the funds have to be spent on children’s service.

The MHSA stipulates that the California State Department of Mental Health (DMH) will contract with county mental health departments (plus two cities) to develop and manage the implementation of its provisions. Oversight responsibility for MHSA implementation was handed over to the sixteen member Mental Health Services Oversight and Accountability Commission (MHSOAC) on July 7, 2005, when the commission first met.

The MHSA specifies requirements for service delivery and supports for children, youths, adults and older adults with serious emotional disturbances and/or severe mental illnesses. MHSA funding will be made annually to counties to:

  • Define serious mental illness among children, adults and seniors as a condition deserving priority attention, including prevention and early intervention services and medical and supportive care
  • Reduce the long-term adverse impact on individuals, families and State and local budgets resulting from untreated serious mental illness.
  • Expand the kinds of successful, innovative service programs for children, adults and seniors already established in California, including culturally and linguistically competent approaches for underserved population.
  • Provide State and local funds to adequately meet the needs of all children and adults who can be identified and enrolled in programmes under this measure.
  • Ensure all funds are expended in the most cost-effective manner and services are provided in accordance with recommended best practices, subject to local and State oversight to ensure accountability to taxpayers and to the public.

Implementation

Starting from enactment, implementation of the MHSA was intended to take six months; in reality, the process of obtaining stakeholder input for administrative rules extended this period by several months. By August 2005, 12 meetings and 13 conference calls involving stakeholders across the state resulted in the final draft of rules by which counties would submit their three-year plans for approval.

Counties are required to develop their own three-year plan, consistent with the requirements outlined in the act, in order to receive funding under the MHSA. Counties are obliged to collaborate with citizens and stakeholders to develop plans that will accomplish desired results through the meaningful use of time and capabilities, including things such as employment, vocational training, education, and social and community activities. Also required will be annual updates by the counties, along with a public review process. County proposals will be evaluated for their contribution to achieving the following goals:

  • Safe and adequate housing, including safe living environments, with family for children and youths.
  • Reduction in homelessness.
  • A network of supportive relationships.
  • Timely access to needed help, including times of crisis.
  • Reduction in incarceration in jails and juvenile halls.
  • Reduction in involuntary services, including reduction in institutionalisation and out-of-home placements.

MHSA specifies three stages of local funding, to fulfil initial plans, three year plans, and long term strategies. No services would be funded in the first year of implementation. The DMH approved the first county plan in January 2006. Allocations for each category of funding were planned to be granted annually, based upon detailed plans with prior approval. However, an amendment to the MHSA, AB 100, which passed in March 2011, serves to streamline the DMH approval and feedback process to the counties, ostensibly to relieve the DMH of some of its administrative burden.

Roles & Responsibilities

While the county mental health departments are involved in the actual implementation of MHSA programmes, the MHSA mandates that several entities support or oversee the counties. These include the State Department of Mental Health (DMH) and the Mental Health Services Oversight and Accountability Commission (MHSOAC).

California State Department of Mental Health (DMH)

In accordance with realignment, the DMH approves county three-year implementation plans, upon comment from the MHSOAC, and passes programmatic responsibilities to the counties. In the first few months immediately following its passage, the DMH has:

  • Obtained federal approvals and Medi-Cal waivers, State authority, additional resources and technical assistance in areas related to implementation.
  • Established detailed requirements for the content of local three year expenditure plans.
  • Developed criteria and procedures for reporting of county and state performance outcomes.
  • Defined requirements for the maintenance of current State and local efforts to protect against supplanting existing programmes and their funding streams.
  • Developed formulas for how funding will be divided or distributed among counties.
  • Determined how funding will flow to counties and set up the mechanics of distribution.
  • Established a 16-member Mental Health Services Oversight and Accountability Commission (MHSOAC), composed of elected State officials and Governor appointees, along with procedures for MHSOAC review of county planning efforts and oversight of DMH implementation.
  • Developed and published regulations and provide preliminary training to all counties on plan development and implementation requirements.

The DMH has directed all counties to develop plans incorporating five essential concepts:

  • Community collaboration.
  • Cultural competence.
  • Client/family-driven mental health system for older adults, adults and transition age youth and family-driven system of care for children and youth.
  • Wellness focus, which includes the concepts of recovery and resilience.
  • Integrated service experiences for clients and their families throughout their interactions with the mental health system.

The DMH, in assuming and asserting its primacy over MHSA implementation, has dictated requirements for service delivery and supports as follows:

  • Full Service Partnership (FSP) Funds: Funds to provide necessary services and supports for initial populations.
  • General System Development Funds: Funds to improve services and infrastructure.
  • Outreach and Engagement Funding: Funds for those populations that are currently receiving little or no service.

Mental Health Services Oversight and Accountability Commission (MHSOAC)

The authors of the MHSA created the MHSOAC to reflect the consumer-oriented focus of the law, mandating at least two appointees with severe mental illness, two other family members of individuals with severe mental illness, and various other community representatives. This diverse commission holds the responsibility of approving county implementation plans, helping develop mental illness stigma-relieving strategies, and recommending service delivery improvements to the state on an as-needed basis. Whenever the commission identifies a critical issue related to the performance of a county mental health programme, it may refer the issue to the DMH.

The first meeting of the MHSOAC was held July 7, 2005, at which time Proposition 63 author Darrell Steinberg was selected unanimously by fellow commissioners as chairman, without comment or discussion. After accepting the gavel, Steinberg was roundly praised for devising Proposition 63’s ‘creative financing’ scheme. Steinberg then said, “We must focus on the big picture,” and stated his priorities with regard to the implementation of the MHSA:

  • Prioritise prevention and early intervention, without falling into the trap of fail first service provision;
  • Address “the plight of those at risk of falling off the edge,”; and
  • Advocate for mental health services from his “bully pulpit.”

MHSOAC Commissioners

In accordance with MHSA requirements, the Commission shall consist of 16 voting members as follows:

  • The Attorney General or his or her designee.
  • The Superintendent of Public Instruction or his or her designee.
  • The Chairperson of the Senate Health and Human Services Committee or another member of the Senate selected by the President pro Tempore of the Senate.
  • The Chairperson of the Assembly Health Committee or another member of the Assembly selected by the Speaker of the Assembly.
  • Twelve appointees of the Governor, who shall seek individuals who have had personal or family experience with mental illness, to include:
    • Two persons with a severe mental illness.
    • A family member of an adult or senior with a severe mental illness.
    • A family member of a child who has or has had a severe mental illness.
    • A physician specialising in alcohol and drug treatment.
    • A mental health professional.
    • A county Sheriff.
    • A Superintendent of a school district.
    • A representative of a labour organisation.
    • A representative of an employer with less than 500 employees.
    • A representative of an employer with more than 500 employees.
    • A representative of a health care services plan or insurer.

State Government Appointees

The initial government officials and designee appointed:

  • Senator Wesley Chesbro (Democrat), of Arcata, chair of the Senate Budget and Fiscal Review Committee and the Senate Select Committee on Developmental Disabilities and Mental Health.
  • Assemblyman Mark Ridley-Thomas (Dem), of Los Angeles, a member of the Assembly Health committee and former L.A. city councilman.
  • Attorney General Bill Lockyer, of Hayward, a former State Senator and Assemblyman.
  • Darrell Steinberg (Dem), of Sacramento, an attorney, the author of Proposition 63, former Assemblyman. Steinberg is the appointee of the Superintendent of Public Instruction.

Governor’s Appointees

On 21 June 2005, then Governor Schwarzenegger announced his appointment of twelve appointees to the MHSOAC:

  • MHOAC Vice Chairman Linford Gayle (declined to state party), 46, of Pacifica, a mental health program specialist at San Mateo County Mental Health Services.
  • Karen Henry (Republican), 61, of Granite Bay, a labour attorney and a board member of California National Alliance for the Mentally Ill (NAMI). Henry is afflicted by ‘rapid cycling’ bipolar disorder, has a son who has autism, and another son with a mental illness.
  • William Kolender (Rep), 70, of San Diego, the San Diego County Sheriff and president of the State Sheriffs Association, a member of the State Board of Corrections, and was for three years the director of the California Youth Authority (CYA). Kolender’s wife died as a result of mental illness, and he has a son with a mental disorder.
  • Kelvin Lee, Ed.D. (Rep), 58, of Roseville, a superintendent of the Dry Creek Joint Elementary School District.
  • Andrew Poat (Rep), 45, of San Diego, former director of the government relations department for the City of San Diego, a member of the public policy committee for the San Diego Gay and Lesbian Centre, and a former deputy director of the United States Office of Consumer Affairs. Poat represented employers of more than 500 workers on the commission, and says he will use his experience building multimillion-dollar programs to bring together mental health advocates.
  • Darlene Prettyman (Rep), 71, of Bakersfield, is a psychiatric nurse, a board member and past president of NAMI California, and a past chairman and a member of the California Mental Health Planning Council. Her son has schizophrenia, and her stated priority is to enhance provision of housing for mental health service clients.
  • Carmen Diaz (Dem), 53, of Los Angeles, a family advocate coordinator with the L.A. County Department of Mental Health and a board member of United Advocates for Children of California. Diaz has a family member with a severe mental illness.
  • F. Jerome Doyle (Dem), 64, of Los Gatos, is chief executive officer of EMQ (a provider of mental health services for children and youth), a board member and past president of the California Council of Community Mental Health Agencies, and a board member of California Mental Health Advocates for Children.
  • Saul Feldman DPA, (Dem), 75, of San Francisco, is chairman and CEO of United Behavioural Health, a member of the American Psychological Association, the founder and former president of the American College of Mental Health Administration, and a former president and CEO of Health America Corporation of California. Feldman was appointed as a health care plan insurer.
  • Gary Jaeger, M.D. (Dem), 62, of Harbour City, is currently the chief of addiction medicine at Kaiser Foundation Hospital, South Bay, a member and former chair of the Behavioural Health Advisory Board of the California Healthcare Association, and former medical director of family recovery services at St. Joseph Hospital in Eureka. He says members of his family have an “80 percent rate of drug and alcohol abuse.”
  • Mary Hayashi (Dem), 38, of Castro Valley, president of the Iris Alliance Fund and a board member for Planned Parenthood Golden Gate and member of the Board of Registered Nursing. Hayashi’s concerns include transportation access for clients and paratransit services, and represents employers with 500 or fewer workers.
  • Patrick Henning (Dem), 32, of West Sacramento, is the legislative advocate for the California Council of Laborers. He was previously the Assistant Secretary at the Labour and Workforce Development Agency (An Agency that he helped create), deputy director for the Department of Industrial Relations and Prior to his State service Special Advisor and Congressional Liaison to President Bill Clinton. Henning is a member of the Career Technical Education Standards and Framework Advisory Group and the California Assembly Speaker’s Commission on Labour Education. He represents labour.

Current Progress

One unqualified success story from the MHSA thus far involves the implementation of Full Service Partnerships (FSPs) demonstrating the “whatever it takes” commitment to assist in individualised recovery – whether it is housing, “integrated services, flexible funding [such as for childcare], intensive case management, [or] 24 h access to care.” FSP interventions are based upon evidence from such programs as Assertive community treatment (ACT), which has effectively reduced homelessness and hospitalisations while bettering outcomes. But the FSP model looks more like that of the also-popular MHA Village in Long Beach, which is a centre that offers more comprehensive services besides those specifically mental health-related. Beyond these guiding principles, however, there has not been much consensus over unifying strategies to define and implement an FSP – resulting in varying FSP structures across counties.

Overall, though, the Petris Centre, funded by the DMH and California HealthCare Foundation to evaluate the MHSA, has reported quantifiable improvements in many areas:

  • Homelessness rates.
  • Entry rates into the criminal justice system.
  • Suffering from illness.
  • Daily functioning.
  • Education rates.
  • Employment rates.
  • General satisfaction with FSPs.

Continued Challenges

According to the UCLA Centre for Health Policy Research, the 2007 and 2009 California Health Interview Surveys (CHIS) demonstrate continued mental health needs of almost two million Californians, about half of which were unmet in 2011. In spite of steady tax revenue ($7.4 billion raised as of September 2011) earmarked for the MHSA, the unremittingly high numbers of mentally ill who lack treatment contrast starkly with the implementation of new programs like the FSPs, which may cost tens of thousands of dollars annually per person. The MHA Village programme, for example, averages around $18,000 annually per person. One of the major growing concerns regarding MHSA implementation is its unintentional but worrying tendency to create silos of care. As directed by the DMH, counties search for “unserved” mentally ill or at-risk individuals to enrol in their new programmes, while keeping existing and perhaps underserved clients in old programs that are usually underfunded, but cannot take MHSA funds. Ironically, while the MHSA was established in part to address racial/ethnic disparities in health care, it may be perpetuating the disparity in services delivery between underfunded and well-funded, new programmes.

A possible solution to this issue highlights another challenge for the MHSA: the need for more comprehensive evaluation, oversight, and advisory mechanisms. Though there is an accountability commission, the MHSOAC, its oversight and regulatory responsibilities are not well-defined. However, it is a relatively new entity, having been created by the MHSA in 2004, and has yet to fully delineate its role in the MHSA. With time, the MHSOAC will hopefully continue to develop towards its stated function. Objective and expert evaluation of the MHSA will also be necessary to achieve the kind of longstanding system-wide improvement that then becomes a model for others.

What are the Principles for the Protection of Persons with Mental Illness?

Introduction

The Principles for the Protection of Persons with Mental Illness and the Improvement of Mental Health Care (MI Principles) were adopted by the United Nations General Assembly in 1991.

Background

The MI Principles provide agreed but non-legally-binding basic standards that mental health systems should meet and rights that people diagnosed with mental disorder should have.

Although the document underwent extensive drafting for 20 years and remains the international human rights agreement most specifically concerned with mental health, it has been criticised for not offering stronger protections in some areas.

It should now be read in the context of the United Nations Convention on the Rights of Persons with Disabilities.

The Principles

There are 25 principles:

  1. Fundamental freedoms and basic rights.
  2. Protection of minors.
  3. Life in the community.
  4. Determination of mental illness.
  5. Medical examination.
  6. Confidentiality.
  7. Role of community and culture.
  8. Standards of care.
  9. Treatment.
  10. Medication.
  11. Consent to treatment.
  12. Notice of rights.
  13. Rights and conditions in mental health facilities.
  14. Resources for mental health facilities.
  15. Admission principles.
  16. Involuntary admission.
  17. Review body.
  18. Procedural safeguards.
  19. Access to information.
  20. Criminal offenders.
  21. Complaints.
  22. Monitoring and remedies.
  23. Implementation.
  24. Scope of principles relating to mental health facilities.
  25. Saving of existing rights.