sionals, well trained or not in family mental health therapy, will enter a system in which autonomy and integrity must be traded off for job security. How many of us here today can relate a story of a person in need being denied treatment, or being put on an extensive waiting list for lack of an available bed? How many of us have experienced what I call the criteria of "most dangercus," in which one person is served over another person person on the basis of a differential diagnosis? Despite any changes we can facilitate in curriculum and training, trained professionals will continue to be "force fit" into the public mental health treatment system. They will continue to be expected to "go along" with state mental health authority "policy." To, as they say, "rock the boat," is to risk one's livelihood, as my wife found when she reported an incident of an aide striking a patient in a Missouri public mental health facility and was read the "riot act" by the attending physician for triggering an investigation. Standard operating procedure stifles professional ethics and morality, while punishing effective advocacy with the loss of employment. Professional training must be thought-provoking, not full of stilted conceptual frameworks developed by high-ranking professionals and professional associations with a stake in the outcome implementation of such frameworks. Professional training should be based in the realities of the current system, not rife with allusions to such things as Rogerian therapy, gestalt therapy, long-term psychotherapy in public settings, etc. Granted some professionals will, in a private setting, practice such interventions. However, it would seem that our universities, traditionally the "incubators" of new ideas in society, should focus mental health education upon changing inadequate systems, not upon avant garde treatments available only to the wealthy. Take as an example the predictability of dangerousness by psychiatry. How many people in this room actually believe wholeheartedly that the average psychiatrist can truly predict the future dangerousness of an individual? How many studies have each of us read that question such a capability? Yet, short of a page or two in a first year graduate class, this topic was not covered in my graduate studies. We need to ensure that all mental health professionals in training are challenged to study such phenomena. Besides predictability, all mental health professionals should be challenged to think through other controversial issues which might include (1) the entire concept of forced treatment; (2) the concept of dangerousness and gravely disabled criteria for forced treatment; (3) the conflict between legally sanctioned psychiatric treatment and the constitutional rights of mentally ill Americans; and (4) the concept of what constitutes "treatment." And last, but not least, upon the public treatment system, and the long term implications, to society and mental health professionals, of its continued existence. Thus, I believe that graduate, medical, and professional students need to be presented with a firm grounding in mental health policy-its relationship to the public and private sectors--and its impact on the individual clinician. Advanced policy studies should address, at a minimum: (1) a firm grounding in the public mental health system of the state in which the school is located; (2) case studies in fiscal mental health policy and its formulation; (3) readings and lectures highlighting the politics of mental health and funding, specifically studying the power of different disciplines, interest groups, professional organizations, and individuals; and (4) studies of current major issues in the field, including such things as abuse and neglect, the rights of individuals and families, the responsibility of society, homelessness, etc. FUNDING THE FUTURE "How do we staff our public mental health facilities with professionals who are capable?" A major complaint of patients and family members is the quality of public hospital physicians (and other professionals). Clearly, the public system is, to the competent caring mental health professionals, a stepping-stone to better paying and more rewarding private practice. We are left, thus, with a public system which retains mediocrity, filled with non-English speaking "psychiatrists" who are usually non-board certified. My home state, Missouri, is currently faced with an acute shortage of qualified psychiatrists. In the near future, the Missouri Department of Mental Health faces a nursing shortage. What type of solution is available to confront such difficulties? Mental health authorities are extremely concerned over their inability to retain quality psychiatrists in the public sector, but the reality is that private practice is much more rewarding to these doctors. The only answer would seem to be increasing the compensation of publicly employed psychiatrists. To improve the current public mental health system will take millions upon millions of dollars. It will take advocacy efforts of gargantuan proportions. The general public will need to to be educated, stigma reduced, and treatments improved. Cooperation will need to be facilitated between some of the key players discussed here today--family members, educators, social workers, psychologists, nurses, psychiatric leaders, leaders, consumers, hopefully, legislators. The list goes on and on. primary The first step on this road is, I believe, re-introducing the federal government into the lives of millions of mentally ill Americans. Somehow, the mentally ill, unlike any other handicapped constituency, have become the responsibility of the states. Indeed, the current administration's reaffirmation of states rights could have been modeled after the public psychiatric system in the United States. The road to federal responsibility will be a long one, but one which can be immediately started with the institution of enhanced federally-funded training programs for mental health professionals. I would propose programs that (1) would offer financial incentives for students with federal loans to work in the public mental health system, and (2) would establish specific scholarship monies for advanced mental health training for former and current consumers of mental health services. Incentives are currently in place at the federal level, forgiving millions of debt dollars in federal loans to doctors who work in rural and poverty areas following graduation from medical school. Similar programs are in place for teachers. Providing incentives for graduates of advanced clinical mental health training to work in the public arena would open up that arena to some of the best and brightest minds. If possible, such an initiative would forgive a certain amount of student loan debt for each year the professional worked in an approved site. Approved sites could include, in addition to traditional state facilities, not-for-profit entities in rural underserved areas, poverty areas, and areas with large numbers of racial minorities. Many graduate students are desperate for paid practicums, but in my state the only way to do so is as an unpaid volunteer. The same type of situation can be construed as existing for psychiatric residents, psychologists, and other mental health professionals. It is not going too far to suggest that we can identify a major problem aspect of the public mental health system in this area. Clearly, any professional student, if given a choice between a paid and unpaid internship, will choose the paid positions. The economics of education demand it, and in fact, to my regret, I did so. Somehow, we must develop funding mechanisms which (1) recruit the best and the brightest into the public mental health system as interns, and (2) provide incentives to retain the skills of those so recruited. The linkage of the recovered patient and advanced clinical education is another idea whose time has come. Consider the influx, in the past 30 years, of physically handicapped citizens into university educations. Consider the success and proliferation of recovered substance abusers into the substance abuse treatment arena. Then consider for a moment, the handicapped mentally ill individual who wishes to return to society in a useful role. What of the experience former chronic mental patients have had as consumers? What of their experiences within the public mental health treatment system? The current consumer movement would indicate that many recovered primary consumers find great fault with the mental health system. But they take the time to become involved in promoting systems change! Some professionals take the position that such recovered patients should be grateful, for, indeed, they have recovered in these systems they now attempt to change. However, that is easily answered by the question asked by many ex-patients, "If the system is so good, then why am I so alone in my recovery?" State and federal initiatives could do so much to access the expertise of former consumers of psychiatric services. Clinical traineeships for former patients currently exist, mainly at the University of Cincinnati. Expansion of such initiatives to all parts of the United States is an idea whose time has come. The recovered patient as a student is not only being trained to use his experience as a clinician. He or she also brings a great deal of knowledge into the classroom. Scholarships, and the like, for ex-patients, would help de-stigmatize mental illness, bringing firsthand knowledge into the classroom. Indeed, being able to get a graduate education at public expense, BECAUSE a person has experienced a mental illness leads that person to, and I am an example of this, view that illness as an asset. it. Ex-patients have a wealth of experience. Let us begin to use CONCLUSION A recent study by David I. Specht, Ph.D., of the Human Resource Association of the Northeast Northeast (under NIMH (under NIMH grant MH17631, SPHRD, DESSL), provides some new information on consumer-ex-patient roles in higher education. Table 1 shows state Community Support Program and primary consumer responses to the question, "Do State Higher Education Institutes Use Consumers?" It would appear that, of the 50 state CSP authorities, and of the consumers from each state queried, that "Guest Lecturer" would seem to be the only substantive role whatsoever played by primary consumers at this point in time. Table 1 Consumer/Ex-Patient Roles in Higher Education* * From: Specht DI: Findings of National Survey of State Support Response to "Incorporating the Consumer's Contribution to Clinical Training" Frederick J. Frese, Ph.D. I have been invited today as a primary consumer/professional to respond to Mr. Link's (1988) paper, entitled "Incorporating the Consumer's Contribution to Clinical Training." In that I have been told that I do not always have the demeanor of a psychologically disabled person, perhaps it would be best if I were to follow Dan Link's lead and establish my credibility by mentioning my "credentials" as a consumer. Back in the 1960's after living in Japan for about two years as a young Marine, I was assigned to duty as a guard officer at a large Naval Air Station in Florida. My fellow Marines and I were responsible for providing security for an atomic weapons storage area and for the Fleet Intelligence Center for Europe. After about nine months in a stressful work environment, I had a breakdown, was hospitalized, and was diagnosed as a paranoid schizophrenic. I was twenty-five years old at the time. During the following eight years, I experienced a series of breakdowns, spending a total of about 300 days in various military, VA, state, county, and private facilities. Since 1974 I have not been further hospitalized, and feel that to some degree I have learned to watch for warning signals in such a way that I can function in a reasonably normal fashion in work and social settings. For about twenty years now I have maintained employment as a psychologist and/or administrator in state operated hospitals in Ohio, and have completed an additional degree in management, as well as completing Master's and Doctoral degrees in psychology and subsequently studying law as a special student at the University of Akron Law School. For the past eight years I have served as the Director of Psychology at a large state hospital, supervising a staff of fifteen to twenty psychology personnel who deliver diagnostic and treatment services to some 600 seriously disabled psychiatric patients. During my work experience I have had responsibility for the training of numerous clinical and counseling psychology graduate students from several local universities. Recently I have also been given responsibility for conducting a clerkship for students from the Case Western Reserve School of Medicine. In the past few years, I have become somewhat involved in the consumers' movement, helping to form helping to form a local consumers' consumers' group, attending the last three national consumers' conferences, and by serving as the primary consumer on the Summit County (Akron, Ohio) Community Mental Health Board. Thank you for your attention to the foregoing biographical information. If I may, I will now proceed to address some of the arguments presented in Mr. Link's paper. That which I consider most important in the paper is the fact that Dan argues that because of his past hospitalizations he has a unique perspective with regard to the mental health system. He goes on to argue that consumers of all types should have a larger role as |