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Consumer/Survivor-Operated Self-Help Programs:
A Technical Report

Chapter One

In 1987–1992, the National Institute of Mental Health’s (and later the Center for Mental Health Services’) Community Support Program (CSP) launched a unique program to fund community-based consumer/survivor demonstration grants. Through this effort, grants totaling nearly $5 million were awarded to 14 States to implement and evaluate an array of services to Americans with severe mental illness provided by mental health consumers/survivors. The goals of this effort were to:

• Address a critical shortage in the number and type of self-help services available to mental health consumers in the community;
• Demonstrate the feasibility and effectiveness of consumer-operated programs;
• Analyze, synthesize, and package findings from these grants so that other consumers/survivors could replicate these services in their local communities;
• Generate a series of recommendations useful to policymakers with responsibilities for funding community-based mental health services; and
• Foster support for sustaining existing programs and increasing the number of consumer/survivor self-help initiatives so that effective services will be available to those who need them.

This document summarizes an examination of the findings of these innovative grant projects focusing on their accomplishments, implementation, operation, and evaluation. A cross-project analysis was used to determine similarities, differences, generalizable observations, and recommendations forimplementing, operating, and evaluating consumer/survivor-run programs.

This report is unique in that it is based on research techniques and has been guided by persons with an understanding of consumer/survivor self-help issues.

The initial method implemented was the identification and summarization of published and unpublished literature on self-help and programs operated by and for consumers/survivors. Project staff completed a literature search with key informants in the consumer/survivor self-help movement, self-help technical assistance centers, national consumer/survivor organizations, self-help researchers, CMHS documents, and other sources. In addition, notices were placed in national consumer/survivor newsletters requesting literature on this topic.

As a result, over 80 pieces of literature were located. These materials have been reviewed while examining such issues as:

• How is "self-help" generally defined? What are the essential characteristics of "self-help"? What is the history and rationale for its use? How has it been instituted in different service fields?
• What is "mental health consumer/survivor self-help"? What is its history and the rationale for its use? What are its major philosophies, goals, values, and outcomes?
• What are consumer/survivor-operated self-help programs? What are the topologies of services delivered? How do the programs differ and how are they similar?
• How are consumer/survivor-operated self-help programs organized to achieve their aims? How are these efforts fund-ed? How are they managed and administered? What sort of staffing patterns exist? What is the population that is served by these efforts? How are these efforts governed? What is the extent of program evaluation and research con-ducted with these programs? How do they interact with traditional, professional-run organizations, each other, and the external environment?

The second major activity focused on review and analysis of information from each of the CSP demonstration grant projects contained in their original proposals, progress reports, evaluation studies, and final reports.

To accomplish this task, a detailed, qualitative, descriptive analysis was conducted for each project which examined the following domains:

• Project goals and objectives;
• Services provided;
• Individuals served;
• Organization and administration;
• Implementation issues and barriers;
• Successes and evaluation findings; and
• Project recommendations.

The final activity centered on conducting analyses across the projects to determine similarities, differences, generalizable knowledge gains, and recommendations for implementing, operating, and evaluating consumer/survivor-run programs.

A comparative analysis of the qualitative findings of each project enabled a synthesis of information about the projects' similarities as well as differences in approaches and services, and it contrasted problems encountered and results achieved. In so doing, a matrix analysis was employed to complete this task. Generalizable observations were extracted from the information in the above domains, and conclusions and recommendations were then drawn from this analysis.

A number of factors affect the validity and reliability of the methodology employed. An important issue is the age of the data. Most of the projects reviewed were initiated approximately 6-8 years before the completion of this report. There are a number of factors which contributed to this, including when the grant for the report was awarded and the time necessary to complete data analyses. While this may, in fact, impact upon some variables (e.g., environmental changes), the results are likely to be relevant and transferable to the present time.

In reviewing literature, it is difficult to complete a comprehensive overview of all sources in this area in that materials are published at a rapid pace. In addition, many pieces of consumer/survivor literature are "fugitive" (e.g.,not published in traditional, peer-reviewed professional journals). With over 80 citations, however, this review does approach a significant overview of this field.

The qualitative analysis of the 13 projects also brings significant limitations. These include the examination of self-reports from the projects themselves and the incomplete data which these reports contain. These issues are explored in greater detail at the beginning of Chapter 2. This factor also impacts upon the matrix analysis conducted to determine cross-site findings and recommendations, because this matrix analysis was based on the project findings themselves.

While the above do produce limitations in the methodology, it is believed that this report does offer a valuable-albeit descriptive-analysis of consumer/survivor-operated programs. As such, it should be a useful tool as consumer/survivor-operated programs further develop.

This report presents a snapshot of the experiences of 13 of the 14 National Institute of Mental Health/Community Support Program (NIMH/CSP) Consumer-Operated Services Demonstration Projects funded during 1988-1989 (one grant was terminated due to irresolvable implementation problems).

The report opens with a brief overview of the literature on the evolution of the consumer/survivor movement to provide a context within which to understand the achievements of the 13 grantees. Chapter 1 continues with an exploration of the benefits, characteristics, and values of consumer/survivor self-help; reviews program typologies and services; and concludes with a description of how consumer/survivor self-help programs have been organized and administered to achieve their objectives.

Chapter 2 provides a detailed overview of each demonstration project funded and examines: project goals and objectives; program description; implementation issues and barriers; and successes and evaluation findings. This will include a review of the services provided, clients served, and issues surrounding project organization and implementation. Project out-comes, recommendations, and continuation efforts are also discussed.

Chapter 3 offers overall findings based on a cross-site analysis of the project narratives. Specifically, this was conducted using a matrix analysis of the key outcomes associated with each project. Generalizable similarities and differences were extracted and are presented.

The report concludes with a set of broad policy recommendations for public officials, researchers, managed care organizations, State mental health programs, local communities, and consumers/survivors for implementing, operating, and evaluating future, community-based consumer/survivor self-help programs.

SELF-HELP: A HISTORY & DESCRIPTION OF THE GENERAL CONCEPT

In 1992, an estimated 4 million Americans experience "severe mental illness", a category that loosely encompasses people suffering from schizophrenia, major depression, and bipolar disorder (Interagency Council on the Homeless, 1992).

Historically, society has shunned, mistreated, and ignored those with serious mental health problems, viewing them as incapable of making decisions and thinking for themselves. Not only have the myths and stigmas surrounding mental illness resulted in numerous instances of discrimination in housing, employment, and education, but they have also produced a class of people who have been systematically disempowered and dependent on what they perceive as a largely unresponsive mental health system (Chamberlin, 1978).

Recently, however, consumers/survivors^* have begun to change their status both in their own eyes and in those of the public. They have become increasingly vocal and active as participants in planning, delivering, and evaluating mental health services that better meet their needs for appropriate treatment, respect personal dignity, and promote independence (Canadian Mental Health Association, 1988; Chamberlin, Rogers, and Sneed, 1989; Specht, 1988; Chamberlin and Rogers, 1990).

As a result of this positive action, there is a growing acceptance of the role of consumers/survivors in the provision of mental health services as well as increasing support for consumer/survivor-operated self-help services (Interagency Council on the Homeless, 1992).

Consumer/survivor-operated self-help pro-grams are a relatively recent phenomenon, and the paucity of information in the literature reflects a field that is still in its infancy. Despite this limitation, a literature review was undertaken of both published and un-published sources of information in order to discover the basic foundations of consumer/ survivor-operated self-help programs. A computerized literature search was completed at the University of Maryland at Baltimore; key researchers and representatives of the consumer/ survivor self-help movement were contacted to obtain materials; and notices were placed in national consumer/survivor as well as professional mental health journals. An Editorial Review Committee composed of consumers/survivors as well as traditional mental health researchers provided guidance in interpreting the information contained in the documents identified through the search.

Webster's Dictionary defines self-help as "the act or an instance of providing for or helping oneself without dependence on others" (Webster's, 1974). In more general terms, it is the process whereby individuals who share a common condition or interest assist themselves rather than relying on the assistance of others.

Over the past 25 years, American society (and the world in general) has witnessed a revolution in the way people access and receive help. The self-help movement has grown so dramatically that self-help and sup-port groups now exist for everything from dream sharing to women's health. Self-help has gained such acceptance that the former Surgeon General of the United States, Dr. C. Everett Koop, observed that " . . . the benefits of mutual aid are experienced by millions of people who turn to others with a similar problem to attempt to deal with their isolation, powerlessness, alienation . . ." (Katz, et al., 1992).

Self-help is not a new idea. People have been organizing to help themselves throughout history. Religious institutions have frequently played this role by offering support for common values, meeting basic material needs, and providing opportunities for socialization to their members. In the political arena, the National Association for the Advancement of Colored People (NAACP), the National Organization for Women (NOW), Mothers Against Drunk Driving (MADD), ACT UP, and countless others form self-help coalitions to redress civil and social wrongs, change policy in the public/private sectors, and promote education (Gartner and Riessman, 1984; Zinman, et al., 1987).

Self-help in the traditional human services arena, however, is a fairly recent development. For decades, service providers have been a highly educated and elite segment of society (Riessman, 1989). The "professionalization" of social work-whereby practitioners are educated in university settings and licensure is becoming a standard requirement for employment-is one example of this practice.

The modern self-help movement traces its roots to Alcoholics Anonymous. Founded in 1935 by two recovering alcoholics, Alcoholics Anonymous, or "A.A." as it is commonly called, is a fellowship of men and women (and, more recently, adolescents) who share their experiences and strength with each other in a group setting, hoping that together they can solve their common problems (Alcoholics Anonymous, 1994; Nace, 1992).

In A.A., alcoholism creates a profound bond between members, all of whom are equal. The line between patient and doctor, professional and amateur does not exist in A.A. Anonymity, the primacy of both the common welfare and group unity, and the absence of hierarchical governance are some of the oter notable hallmarks of Alcoholics Anonymous (Nace, 1992).

While the A.A. program is deceptively simple-focusing on the "12 steps" or principles that members follow to maintain sobriety-it has attracted an enormous following: approximately 50,000 A.A. groups exist in North America today.

The work and message of Bill W. and other pioneers of A.A. were the impetus for an entirely new philosophy that held that people do not have to rely on "experts" in order to improve their condition (Bufe, 1991; W., Bill, 1955). A.A.'s success has prompted, in turn, a fundamental shift in ideas about the provision of "help" which has resulted in the blossoming of self-help that is seen today.

The contemporary self-help movement exploded during the late 1960's and 1970's as people began to question the status quo of traditional society and began to explore a wide range of "alternative" ideas and behaviors from political philosophies, to sexual mores, to methods of assisting and empowering one another. A.A.'s 12-step model has spawned self-help and peer support groups for virtually every health issue of concern to present-day society. These include such offspring as Narcotics Anonymous, Fundamentalists Anonymous, and many non-12-step model programs for people with mental retardation, as well as those with developmental and physical disabilities (White and Madera, 1992).

Millions of individuals have participated in self-help groups of one type or another (Mental Health Policy Resource Center, 1991), and numerous Statewide, national, and even inter-national information clearinghouses on self-help groups have been organized in response (White and Madera, 1992; Gartner and Riessman, 1984). Clearly, there is something about self-help which attracts adherents and produces positive benefits for its members (Stroul, 1986).

Many tangible benefits are cited by self-help group members as promoting their continued participation:

• Peer Support. The ability of group members to be empathic and compassionate based on a common experience assists participants in feeling better by helping them to realize that they are not alone. Self-help actualizes the concept of "strength in numbers". The sense of solidarity, encouragement, and power de-rived from the group imbues participants with the sense that they can persevere. Being a member of a group or community also instills a sense of belonging and of being accepted for whom one is (Riessman, 1989).
• Coping Strategies. Self-help group members share information and insights developed as a result of their own experiences to help each other "get through tough times" (Gartner and Riessman, 1984).
• Role Models. Self-help group members serve a positive role models to one another. Group members who see that others are able to overcome problems and conditions like their own have a renewed sense of hope and energy that "if they can do it, so can I" (Gartner and Riessman, 1984).
• Affordability. Self-help is often free or inexpensive, which makes it a very attractive alternative to high-cost and frequently time-limited "professional" services (Riessman, 1989; Chamberlin, Rogers, and Sneed, 1989).
• Education. Self-help groups serve as a valuable forum for not only exchanging information about members' common concerns, but also for learning about other resources available in the community. For example, self-help groups often invite speakers to discuss issues of special relevance to their membership such as the Social Security Administration's SSI/SSDI benefits (Rogers, J., 1988).
• Advocacy. Case and systems-change advocacy are other attractive features of self-help programs. Through group advocacy efforts, many group members are able to access previously unavailable resources. In addition, members gain intrinsic rewards from joining together to change systems or external environmental conditions that are negatively affecting the self-help community (Zinman, et al., 1987).
• Non-Stigmatizing. Self-help avoids the stigma and negative connotations that are often associated with seeking traditional, professional support (i.e., those who seek professional services are somehow weak in mind or body). This may be related to self-help's emphasis on rugged individualism and self-reliance, traits that the larger society seems to value (Riessman, 1989).
• "Helper's Principle". Proponents of self-help believe that those who are able to provide some support or assistance to others experience a heightened sense of self-worth and self-esteem themselves. This belief is known in the consumer/ survivor community as the "helper's principle", and, in various forms, is a mainstay of the self-help movement (Gartner and Riessman, 1984; Roberts and Rappaport, 1989).

In addition to the benefits attributed to self-help by its members, it also possesses a number of other features that distinguish it from traditional forms of professional services:

• Non-Reliance on Professionals. While some self-help groups take on a decidedly anti-professional stance based on negative personal experiences (i.e., one group is entitled "Victims of Professionals"), the emphasis in the majority of self-help groups is on the practice of self-determination and empowerment. In self-help groups, individuals are encouraged to makethe choices and decisions that affect their lives rather than having these decisions made for them (Riessman, 1989; Stroul, 1986).
• Voluntary. Traditionally, self-help services are voluntary in nature. There is no coercion or requirements that individuals participate in the group. Most individuals attend the self-help function based on their choice and of their own volition (Gartner and Riessman, 1984; Zinman, et al., 1987).
• Equality. Self-help is egalitarian and peer-based. The concept is rooted in a non-hierarchical principle whereby every member has equal status. Leadership is often shared, and facilitation of group discussion is rotated among the members (Zinman, et al., 1987).
• Non-Judgmental. Self-help is based on peer support that is provided in a non-judgmental atmosphere where individu-als can share their feelings and thoughts openly. Respect for a person's confidentiality is emphasized, as well.
• Informality. Informality is generally the norm with self-help groups (Gartner and Riessman, 1984). Boundaries between "professional" and "patient" do not exist, nor do the cumbersome administrative arrangements frequently associated with professional services.

Self-help programs have been instituted in a number of different fields including substance abuse treatment, education, housing, corrections, and physical and mental disabilities.

Alcohol and other drug abuse treatment and recovery services are certainly the most obvious areas where self-help has prospered. Virtually all drug and alcohol treatment pro-grams today include or espouse participation in some form of self-help (e.g., Alcoholics Anonymous, Narcotics Anonymous, Cocaine Anonymous). Recovering individuals are employed in many treatment settings and have been found to be highly effective counselors. The experience of having "been there" enables recovering substance abusers to establish a rapport with clients that other counselors can-not. They are also able to serve as both effective role models and educators, transmitting "reality-based" coping strategies, information, and relapse prevention techniques that other treatment personnel either do not know or cannot convey in quite the same way (Riessman, 1989).

In the field of education, peer counselors and peer tutors have been successful in improving the academic performance and in-school behavior of students at risk for failure or dropping out. Informal study groups also are routinely utilized by students at all levels as a form of self-help (Riessman, 1989).

Self-help strategies have been particularly effective in the area of housing development. Self-help organizations such as the National Union of the Homeless and its local chapters and affiliates (including the Oakland Independence Support Center and the Philadelphia-based Committee for Dignity and Fairness for the Homeless) have operated their own shelters for their members and have devised a number of innovative methods for developing and obtaining permanent housing. Additionally, these groups have produced employment opportunities for their members through such business enterprises as the publication of free community newspapers (National Association of State Mental Health Program Directors, 1992; National Resource Center on Homelessness and Mental Illness, 1989; Long with Van Tosh, 1988a).

Following the lead of the education field, the correctional system has incorporated the concept of peer support into its counseling pro-grams for young offenders. This form of self-help assists its members to improve their life skills with the goal of preventing criminal recidivism and ongoing incarceration (Riessman, 1989).

Physical and mental disabilities are another major area where principles of self-help have been applied effectively (Riessman, 1989; White and Madera, 1992). People who are deaf or hard-of-hearing, for example, have formed self-help support groups such as SHHH (Self-help for the Hard-of-Hearing) and have mobilized to initiate systems change activities (e.g., insisting on the appointment of an educator with a hearing impairment as President of Gallaudet University). As another example, during the past 20 years, consumer-run Centers for Independent Living have developed for individuals with an array of physical and mental disabilities through the Independent Living movement. Services pro-vided through these self-help oriented centers include information on accessing resources, locating housing, peer counseling, and advocacy services, among others. Independent Living Centers also are opening their doors to mental health consumers/survivors through such programs as the National Empowerment Center (a Federally funded consumer/survivor self-help technical assistance effort based at the Northeast Independent Living Center in Lawrence, Mass.) (DeJong, 1979).

THE MENTAL HEALTH CONSUMER/SURVIVOR MOVEMENT

"Mental health consumer/survivor self-help"is the process by which mental health consumers/survivors provide assistance to one another based, to a large extent, on the tenets of the self-help paradigm described in the preceding section of this report.

The mental health consumer/survivor self-help movement began in its modern form approximately 25 years ago. Prior to that, a scattering of consumer/survivor self-help efforts were initiated (Zinman, et al., 1987), including the work of Clifford Beers-a consumer/survivor advocate, author of A Mind That Found Itself, and founder of the Mental Health Association.

In the late 1960's and early 1970's, the increasing popularity of self-help movements in general, coupled with the greater awareness of the abuses that consumers/survivors experienced (partly as a result of media exposés and the film version of the book One Flew Over the Cuckoo's Nest), prompted small groups of consumers/survivors to begin organizing in the larger East and West Coast cities (Madness Network News Reader, 1974).

These groups were few in size and number and took a decidedly militant viewpoint against psychiatry and the established mental health system. Groups with names like the "Alliance for the Liberation of Mental Patients" and "Project Release" met in homes and churches and first drew their membership from the ranks of those with first-hand knowledge of negative experiences with the mental health system (Madness Network News Reader, 1974). However, they sustained their membership by providing: peer; education about services in the community and about the problems consumers/ survivors were facing; and advocacy to help members access services as well as to change an often oppressive system (Furlong-Norman, 1988).

Some of these groups published their own, often impressive, newspapers and magazines (e.g., Madness Network News, Phoenix Rising) to provide education and information to their members. Others conducted advocacy through such direct actions as protests and pickets both at hospitals accused of being abusive and at conventions of the American Psychiatric Association (Madness Network News Reader, 1974).

Members of these East and West Coastself-help groups met at the International Conference on Human Rights and Against Psychiatric Oppression and later at the National Institute of Mental Health's Learning Community Conferences where they would informally network to share information on what they were doing in their local areas.

Over time, the numbers and types of groups began to grow, and more moderate viewpoints came to be represented. Groups such as Emotions Anonymous; Recovery, Inc.; and GROW focused more on peer support and far less-if at all-on advocacy, while others even welcomed the involvement of professionals in their activities (Kaufmann and Freund, 1988; Emerick, 1990; Roberts and Rappaport, 1989).

The publication of Judi Chamberlin's seminal work, On Our Own, was a milestone in the history of the movement. Consumers/survivors and others now could read in the "mainstream" press what it was like to have experienced the mental health system. On Our Own also provided details about the mental health consumer/survivor self-help movement and discussed the extension of this concept into the development of consumer/survivor-run services. For many consumers/survivors, reading this book was the beginning of their involvement in the consumer/survivor movement (Chamberlin, 1978).

In the 1980’s, the National Institute of Mental Health (NIMH) began to support technical assistance to further develop the self-help model. Through its Community Support Program (CSP), NIMH (and later, CMHS) funded a monthly teleconference out of Boston University’s Center for Psychiatric Rehabilitation (Furlong-Norman, 1988). During these calls, consumers/survivors from around the nation could talk with one another about issues of mutual concern as well as discuss what was happening in their local communities. In addition, funds were provided for the publication of a technical assistance manual by the California Network of Mental Health Clients entitled Reaching Across (Zinman, 1987). The Mental Health Association of Southeastern Pennsylvania also received NIMH funds to provide infor-mation on consumer/survivor self-help (Furlong-Norman, 1988).

In 1985, again with funding from NIMH/CSP, the first national conference of consumers/ survivors was held in Baltimore, Maryland, to provide technical assistance and opportunities for networking and information exchange. This meeting, called “Alternatives ‘85”, was at-tended by approximately 400 people and proved so popular that it became an annual event. By 1991, the “Alternatives” conference held in Berkeley, California, drew close to 2,000 participants from virtually every State in the Union and a number of foreign countries (Acker, 1990; Twedt, 1990). Since that time, the conferences have continued to be held with similar attendance.

During this period, the number of con-sumer/ survivor self-help groups expanded rapidly. Today, there are an estimated 3,000 consumer/survivor self-help organizations functioning at the local, State, national, and even international levels (O’Hagan, 1991; European Client Unions Network, 1992; World Federation of Psychiatric Users, 1992). Consumer/survivor self-help groups coordinate activities and conduct advocacy on a Statewide level in approximately 30 States. Various national organizations—for example, the National Alliance of Psychiatric Survivors and the National Mental Health Consumers’ Association—have evolved. In 1992, the World Federation of Psychiatric Users—the first international consumer/ survivor organization—was initiated.

The NIMH/CSP also funded two research centers to examine the phenomenon of con-sumer/ survivor self-help. These centers, located in Michigan and California, have undertaken research that is now producing useful results (Segal, et al., 1991; Boltz, 1992). In 1992, NIMH/CSP expanded its support to fund two technical assistance centers in Massachusetts and Pennsylvania.

In addition to these Government-sponsored initiatives, a number of national publications by consumers/survivors, including Dendronand NAPS News, also have provided information about the growing consumer/survivor move-ment (Oaks, 1992; Unzicker, 1992).

People participate in consumer/survivor self-help for the same reasons that they participate in other self-help groups; namely, for peer-based support, assistance in developing coping strategies, exposure to relevant role models, affordability, pertinent information about issues and services, advocacy for systems change, the opportunity to interact without stigma, and the sense of well-being and self-esteem that derives from helping others (Borck, 1983; Fleming, 1983; Van Tosh, 1990; Roberts and Rappaport, 1989).

In addition to these factors, consumer/survivor self-help enjoys broad support because it works. Studies are currently being completed that document the value of consumer/survivor self-help as a tool in helping people cope with and overcome their individual and collective problems as well as the stigma and discrimination encountered in the external environment. Recently, CMHS has begun planning a study examining the types of services provided by consumer/survivor self-help efforts. This "inventory" will begin to document the significant contributions that these projects provide.

The values and philosophies that guide consumer/survivor self-help are the driving forces behind its development and its success. With other self-help movements, it shares the belief in: peer-based support and assistance; non-reliance on professionals; voluntary member-ship; egalitarian, non-bureaucratic, and informal structure; affordability; confidentiality; and non-judgmental support. However, mental health consumer/survivor self-help also holds specific values and beliefs.

The concept of "empowerment" is central to the belief system of the consumer/survivor self-help. For mental health consumers/survivors, empowerment means acquiring the ability to make those decisions that directly affect their lives. Specifically, this translates into the ability to make decisions about housing, jobs, and services where consumers/survivors have typically had little input (Zinman, 1987; Ridgway, 1988b).

Empowerment on an individual level also translates into control over one's life. Traditionally, consumers/survivors have been falsely deemed "incapable" of playing this role. Empowerment infuses individuals with a sense of self-worth and belief in their capacity to "do for themselves" (Ridgway, 1988b).

On the group level, empowerment refers to the capacity to impact the systems that affect members' lives. True representation, as opposed to tokenism on such decision-making bodies as county mental health services boards, is an example of a form of empowerment that has been put into action (Ridgway, 1988b).

The concept of independence is another central value of consumer/survivor self-help. Historically, consumers/survivors have been dependent on others (particularly in the mental health system) to meet their basic needs and for support. In contrast, the consumer/survivor self-help movement stresses the importance of striving for independence, self-reliance, and the opportunity to function as productive citizens (Zinman, 1987).

The consumer/survivor self-help movement emphasizes the responsibility that individuals must take for themselves and others (National Mental Health Consumers' Association, 1987a). In addition, behaving in a responsible way with respect to one's community is encouraged. For example, when other consumers/survivors are discriminated against in housing or employment, self-help group members are expected to respond and take action to redress those wrongs.

Choice in services and opportunities is also a value of consumer/survivor self-help (Stroul, 1986; Van Tosh, 1989a). In the past, consumers/survivors had little choice in the kinds of services and supports they received. In some instances, such as involuntary treatment, choice was completely eliminated. One goal of the self-help movement is to create an environment in which consumers/survivors can make informed choices about treatment, housing, and other needed services (Ridgway, 1988a).

A key value of this movement is that everyone should be treated with respect and dignity regardless of his or her situation, income, education, or status. The consumer/survivor self-help movement is committed to the idea that all individuals are valuable and have skills and strengths to offer society. The movement also stresses that everyone has rights that should be protected at all times (National Mental Health Consumers' Association, 1987a).

Many segments of the consumer/survivor self-help movement (although not all), value social action as a mechanism for social change. Advocating for changes in how consumers/survivors are treated by the mental health system and society at large is a core activity for many in the consumer/survivor movement (although other segments of the larger self-help movement, particularly Alcoholics Anonymous, take a firm non-advocacy stance). Within consumer/survivor self-help groups, fostering change takes various forms from individual advocacy (e.g., assisting individuals with accessing benefits) to direct action and civil disobedience campaigns (Van Tosh, 1990; National Mental Health Consumer Self-help Clearinghouse, 1988b; Rogers, 1990; Andre, 1992; Zinman, 1987).

Although they share these features in common with other self-help groups, mental health consumer/survivor organizations place an extraordinary value on peer support, hope, and recovery.

Given the history and structure of the prevailing mental health system, consumer/survivor self-help groups view as crucial the capacity to provide emotional support and counseling on a peer level without the power differentials inherent in professional treatment. Developing a peer support network takes on a special importance for people who have mental health problems and have become socially isolated due to attendant stigma and discrimination (Leete, 1988).

Hope and recovery, likewise, are fervently embraced core values. The consumer/survivor self-help movement promotes and reaffirms the fact that people can recover from their often traumatic experiences. In so doing, the movement also fosters the understanding that when systems, communities, and individuals dispense with stereotypes, everyone benefits. As system changes begin to open the doors to improving the quality of life for consumers/survivors, the movement is increasing its focus on the values of hope and recovery and their power to transform attitudes and behavior (Deegan, 1988; Anthony, 1993).

While there is considerable agreement on an acceptance of the majority of values just de-scribed, there is a diversity of philosophies in the consumer/survivor self-help movement relating to the professional mental health system. These differences enabled both Chamberlin and Emerick to distinguish consumer/survivor self-help groups from oneanother and classify them into three categories according to their position on this issue (Chamberlin, 1978; Emerick, 1990).

In the first category are those groups who take an exclusively anti-psychiatric stance towards the mental health system (which they regard as oppressive) and refuse to work with it. Groups in this category rarely include non-consumers/survivors in leadership roles and view self-help activities as an alternative model to the mental health system. For these groups, which some label "radical", the self-help movement is a liberation struggle (Chamberlin, 1978; Zinman et al., 1987; Emerick, 1990).

The second category consists of those groups that work with the system, despite being critical of it. While these groups may include non-consumers/survivors within their general membership, consumers/survivors constitute the majority and maintain leadership positions. These groups, sometimes referred to as "moderate", see the system as needing improvement. However, they also see it as providing some benefits to others (Chamberlin, 1978; Emerick, 1990).

In the third category are those groups who work very closely with the professional system, involve professionals in their activities and commonly share leadership between professionals and consumers/survivors. Self-help groups in this category, sometimes referred to as the "partnership" model, believe that the mental health system is a source of positive help for people with mental health problems and see self-help activities as an adjunct-and not an alternative-to the professional system (Chamberlin, 1978; Emerick, 1990).

There is a great mix of beliefs within consumer/survivor self-help groups that cross the boundaries between categories; neither groups nor individual group members fit neatly into "little boxes". Since a major goal of the consumer/survivor movement is to reduce the use of "labels" by fostering the recognition that diversity should be respected, classification schemes are only one approach to under-standing self-help groups and should be interpreted cautiously.

Accepting government funding for alternative self-help projects as well as participating in collaborative projects with the mental health system has been a subject of ongoing debate within the consumer/survivor movement. Those opposed to "taking government money" fear being co-opted, while those accepting funds view it as a pragmatic step that allows their groups to implement needed services for consumers/survivors.

The two Federally funded research centers and a cadre of independent researchers are in the process of evaluating the impact of the mental health consumer/survivor self-help movement on both individual members and on the larger mental health system.

On an individual level, preliminary research suggests that the benefits of participation in consumer/survivor self-help include: increased independence and self-reliance; improved self-esteem; enhanced coping skills and feelings of personal empowerment; and increased knowledge of services/rights, housing, employment, and other issues of special concern to mental health consumers/survivors. In addition, as a result of their involvement in the movement, a growing number of consumers/survivors are "going public" about their problems and are speaking out against societal stigma (Roberts and Rappaport, 1989; Borck, 1983; Leete, 1988; Van Tosh, 1990).

On a systems level, the movement has substantially contributed to the increased involvement of consumers/survivors in all aspects of the planning, delivery, and evaluation of mental health services as well as in the protection of individual rights. Specific examples of the positive outcomes achieved as a result of their involvement include: Public Law 102-321 (formerly P.L. 99-660), which established mental health planning councils in every State, and the development of Protection and Advocacy agencies for patients' rights in every State (Chamberlin and Rogers, 1990). Both of these laws also include a requirement for substan-tive consumer/survivor involvement in planning and implementing mandated activities.

The consumer/survivor self-help movement also has had a substantial influence on increasing the utilization of consumers/survivors as employees in the traditional mental health system as well as in other areas (Specht, 1988; U.S. Department of Education, 1990; Schlageter, 1990; Interagency Council on the Homeless, 1991). Consumers/survivors are being hired at all levels in the mental health system, ranging from case manager aides to management positions. As consumers/survivors enter into leadership positions, many leaders in the field are also disclosing their own mental health histories (Furlong-Norman, 1991 and 1988).

A significant development has been the establishment of Offices of Consumer Affairs (OCAs) in nearly 30 State Mental Health Authorities. OCAs are generally staffed by consumers/survivors to support consumer/survivor empowerment and self-help in their particular States. In 1995, CMHS hired its first Consumer Affairs Specialist.

With the passage of the Americans with Disabilities Act (ADA) in 1990, employment in fields outside the mental health sphere has become, for the first time, an achievable goal for consumers/survivors. This landmark legislation not only makes it possible for persons with disabilities to obtain employment, but also it may assist people with disabilities to maintain a job. In addition, the ADA makes provisions for training consumers/survivors to use the legislation appropriately. In the process, employers who otherwise would not be aware of this important legislation will also be educated about the rights of Americans with disabilities and their responsibilities as employers to accommodate special needs in the work-place (Furlong-Norman, 1991).

EVOLUTION OF MENTAL HEALTH CONSUMER/SURVIVOR-OPERATED
SELF-HELP PROGRAMS

One of the most significant outcomes of the consumer/survivor self-help movement has been the development of mental health consumer/survivor-operated programs.

Consumer/survivor-operated self-help programs are services that are planned, delivered, and evaluated by consumers/survivors themselves, although some programs incorporate the use of professionals certain areas of planning, implementation, and evaluation (Fleming, 1983; Stroul, 1986).

The majority of consumer/survivor-operated self-help programs are characterized by the values and goals delineated in the discussion of the consumer/survivor self-help movement and, as such, are quite different from those ascribed to traditional professional mental health services. As its name implies, in consumer/survivor-operated programs, the role of consumers/survivors is changed from service recipients to service providers, or what Frank Riessman terms "prosumers" (Riessman, 1989).

Consumer/survivor-operated services (other than self-help/support groups) are relatively new. One of the earliest consumer/survivor-operated services is Fountainhouse in New York City. Founded by a consumer/survivor in the 1950's, it has become the world-renowned leader of the "clubhouse" movement that provides psychosocial and vocational rehabilitation. Today, however, Fountainhouse is no longer consumer/survivor-operated. Although consumers/survivors are still involved, professional staff assist the pro-gram's "members" (Chamberlin, 1978).

Another early consumer/survivor-operated self-help program, the Mental Patients Association (MPA) of Vancouver, met a similar fate. MPA began as a drop-in center where consumers/survivors could socialize, participate in self-help groups, conduct advocacy, and obtain assistance in accessing other services, among other activities (Chamberlin, 1978). In consumer/survivor-operated drop-in centers, the participants plan and administer its programs and serve as staff. Drop-in centers frequently operate during evening, weekend, and holiday hours when traditional programs are closed (Long with Van Tosh, 1988a).

MPA expanded its operations to include a housing program for consumers/survivors. Originally a decidedly "radical" organization, over time, MPA became increasingly professionalized and hired professionally educated staff.

Not all consumer/survivor-operated self-helpprograms have followed this path, however. Some have maintained their original values and their principles and have thrived in the process. One of the oldest programs of this kind is the Ruby Rogers Advocacy and Drop-In Center in Cambridge, Massachusetts. Founded in the early 1970's, it remains a consumer/survivor-operated program today. Another drop-in center, On Our Own, is a fixture among consumers/survivors in Baltimore,Maryland, where it has been steadily providing alternative services for more than 10 years (Stroul, 1986).

The range of services that consumers/ survivors are now operating is diverse and continues to grow (Barry, 1991; Furlong-Norman, 1988; Ohio Department of Mental Health, 1990). Brief descriptions of 12 of the most common forms of services follow.

Programs based on the drop-in center model now operate in many States in a variety of set-tings ranging from small church basements to over 5,000 square-foot properties. Some drop-in centers operated on a "shoe string" budget. Consumers/survivors serve as volunteer staff and programs operate one night per week. Others have budgets of over $150,000, employ fulltime staff, and operate seven days a week. Some drop-in centers are established solely to provide opportunities for social inter-action, while others offer a wide variety of different activities (Long with Van Tosh, 1988a).

Housing programs are another service being operated increasingly by consumers/survivors. Housing options available under these pro-grams range from various kinds of group housing (including a low-demand residential program) to supported independent living arrangements. Collaborative Support Programs of New Jersey has sponsored the development of a unique partnership between a nonprofit housing rehabilitation/development corporation and a local Mental Health Association to provide housing alternatives to consumers/survivors (National Association of State Mental Health Program Directors, 1992). Counter Point in Salt Lake City, Utah, is also collaborating with the local public housing authority to locate housing for some of its members, while Safe Harbor Housing of Rhode Island is both developing and operating housing services by and for consumers/survivors (National Association of StateMental Health Program Directors, 1992).

Consumers/survivors are also developing services geared towards consumers/survivors experiencing homelessness. Examples include: Project Acceptance, a drop-in center located in Lawrenceville, Kansas, that pro-vides housing services for persons who are homeless; Project OATS, a street outreach and advocacy program operating in Philadelphia, Pennsylvania; and the Oakland Independence Support Center, a multiservice center in Oakland, California (National Association of State Mental Health Program Directors, 1992; Long with Van Tosh, 1988a; Interagency Council on the Homeless, 1991).

Consumers/survivors are now operating their own case management programs (Furlong-Norman, 1991). An NIMH CSP-funded research demonstration project in Philadelphia investigated the effectiveness of consumers/survivors as intensive case managers (Solomon, 1992). It found that consumers/survivors were as effective as non-consumers/survivors in providing case management serv-ices. In New York, the Bronx Psychiatric Center has incorporated consumer/survivor peer specialists into case management teams, while in Sacramento, California, consumer/survivor community support services coordinators are employed to assist "clients" in accessing nontraditional case management services (Furlong-Norman, 1991). To prepare consumers/survivors to work as case management aides, Colorado offers a special training program in case management for consumers/survivors.

Consumers/survivors also are operating respite programs for those in emotional crisis (Stroul, 1986). These programs provide a safe, supportive, and comfortable setting where individuals can obtain some relief from their problems without the stress, coercion, and often public shame associated with traditional, professional crisis response services. Telephone hotlines, as well as temporary shelter during crises, are key features of these services. Project Acceptance has begun to provide these services for its members, as does the Next Step Respite Center in Ohio (Ohio Department of Mental Health, 1990).

Consumer/survivor-operated benefits acquisition projects like BACUP in Los Angeles assist their peers in accessing benefits and services to which they are entitled (e.g., Social Security, housing). Consumers/survivors report trusting and feeling comfortable with peers who have experienced problems similar to their own (Long with Van Tosh, 1988a). Some benefits acquisition programs also provide assistance with case advocacy in order to protect the rights of consumers/survivors.

Consumers/survivors operate many types of anti-stigma services including repertory companies (Project Return Players), speakers bureaus (Project Overcome), slide presentations (PCPL), and video productions (White Light Communications) (Rogers, S., 1988; Lovejoy, 1988; Schlageter, 1990).

Many consumer/survivor-operated self-help programs also provide advocacy services to their members in an effort to provoke fundamental change. The Alliance of Syracuse, New York, for example, has sponsored educational training for consumers/survivors across the country who wish to learn more about advocacy skills. The Alliance has also been an ardent supporter of individual patients' rights and has provided support to persons in need of advocacy (The Alliance, 1993).

Consumer/survivor-operated research programs are a very new development. Currently, Well-Being Programs, Inc., and the Consumer/Survivor Work Group on Policy and Research have pioneered consumer/survivor involvement in research, evaluation, and data issues.

The consumer/survivor-operated National Empowerment Center in Massachusetts and the National Mental Health Consumers' Self-help Clearinghouse in Pennsylvania are fund-ed to provide technical assistance to help other consumers/survivors implement self-help programs and address other issues. In addition, a number of consumer/survivor-operated organizations sponsor training workshops, conferences, and seminars to transmit needed information and techniques to other consumers/survivors.

Consumers/survivors have also conducted employment programs that include job training/placement efforts (the former group ACT NOW in Pennsylvania) and job support groups (I CAN in Lancaster, Pennsylvania). In addition, there are a growing number of consumer/survivor-operated businesses, especially in Ohio, which include such enterprises as a jewelry cooperative (Jewelry Plus Craft Cooperative); a tea house (Shining Reflections); and a landscaping business (Your Personal Landscaping and Cleaning Company) (Ohio Department of Mental Health, 1990).

With the recent development of Medicaid man-aged mental health care, consumers/survivors have begun to respond by organizing and educating themselves on how this will affect their services and their lives. A notable effort has been the Consumer Managed Care Network which has developed a "Platform for Action", indicating, from a consumer perspective, qualities of a responsive managed care system (Consumer Managed Care Network, 1996).

Mental health consumer/survivor-operated self-help programs are organized in a variety of ways to achieve their aims. While the type of service dictates organizational specifics, the literature suggests that there are similarities among programs. As mentioned earlier, consumer/survivor-operated efforts are based on the values and guiding principles of the consumer/survivor self-help movement. Thus, egalitarianism is fostered as well as a non-hierarchical approach. Peer support, empowerment, and respect for individuals are also promoted (Zinman, et al., 1987; Segal, et al., 1991).

The differences come into play when these values are operationalized. While some pro-grams take a firm line in adhering to egalitarian and non-hierarchical values, others do not. The question then becomes: does a consumer/survivor-operated self-help organization ceaseto exist when it no longer practices its stated values (Zinman, et al., 1987; O'Hagan, 1991)? The CSP Consumer/Survivor-Operated Services Demonstration Projects described in Chapter 2 provide some preliminary information that will be useful in answering this question.

Funding for consumer/survivor-operated self-help programs originated from a mix of sources, including: grants from Federal, State, and local Mental Health Authorities, foundation and corporate grants, membership dues, and private donations. The majority of programs receive a relatively small amount of money for operations (Zinman, et al., 1987; National Mental Health Consumer Self-help Clearinghouse, 1991; Yaskin, 1992a).

Some organizations have objected to the use of Government funds because of the potential for co-optation. Others view them as funds that consumers/survivors have earned through paying taxes and to which they are entitled. The few organizations with large budgets (over $500,000/year) have relied primarily on governmental funding. It is clear, however, that the majority of consumer/survivor organizations have difficulty raising the resources necessary to accomplish their aims due to the current economic health of the Nation, the lack of focus on human services, and the persistent stigma that is attached to "mental illness" and consumers/survivors (Furlong-Norman, 1988a).

Although consumer/survivor self-help organizations strive to manage and administer their programs in accordance with the values of the movement, a number of different leadership patterns have developed. Ideally, there would be no formal leadership or leadership would be shared among all the project's members or staff. A few programs adhere to this strategy and also attempt to use a consensus model, whereby everyone must agree on a particular course of action before it is implemented. At the other end of the spectrum are organizations that have become hierarchical and bureaucratic as they have grown larger. In these programs, leadership is clearly defined. In the middle, where most projects probably lie, there is a mix of leadership and decisionmaking styles. For example, while a program may have formally defined leaders, democratic participatory management practices are also employed (Zinman, et al., 1987; Emerick, 1989).

Staffing patterns also vary greatly from organization to organization. Since most consumer/survivor self-help programs have insufficient funding to support paid staff, volunteers often comprise the majority of the workforce. In some programs, job responsibilities are shared and staff work part-time (Zinman, et al., 1987; Yaskin, 1992a).

It appears that the availability of support on the job (a feature that appears to be inherent in consumer/survivor organizations) is very important for consumers/survivors to succeed in the work place. In keeping with the Americans with Disabilities Act, consumer/survivor-operated services provide greater "reasonable accommodations" (e.g., "flextime", additional breaks, time off for appointments) to their staff members than more traditional organizations do and are more sensitive to the issues their employees face.

Given that research and evaluation have not yet become standard activities for these consumer/survivor-operated programs, it is difficult to accurately define the population that they serve. From the literature, it appears that they serve people who are hesitant to utilize existing traditional professional services for a number of reasons, including: the past treatment they have received; the cost of traditional services; the amount of support provided at consumer/survivor programs versus traditional programs; and the stigma associated with seeking professional services. Depending upon their location, some mental health consumer/survivor-operated self-help programs may serve only a few individuals a week, while others in heavily populated urban areas may serve hundreds in the same time period (Gartner and Riessman, 1984).

Governance of consumer/survivor-operated programs tends to follow the values of the movement. In most programs, Boards of Directors are composed entirely of consumers/survivors. Those that depart from this practice usually have a majority representation of consumers/survivors. Of these programs, some deliberately offer a Board position to a high-profile community member or attorney in order to obtain expertise in a particular area. These consumer/survivor-operated programs believe that this practice is permissible, as long as consumers/survivors constitute the clear majority on the board (Zinman, et al., 1987).

Research and evaluation on consumer/survivor-operated programs is sparse; the findings presented in this report comprise the most comprehensive examination of its kind to date. However, some individual programs (e.g., Project OATS in Philadelphia) have completed evaluation studies that demonstrate that consumers/survivors are successful in providing services to their peers (Van Tosh, 1990). The two Federally funded research centers mentioned earlier are pursuing research into the issue of consumer/survivor self-help and a number of independent researchers (e.g., Phyllis Solomon, Julian Rappaport, Caroline Kauffman, and Athena MacLean) are also beginning to investigate this phenomenon further. Recently, for example, Solomon released findings indicating that consumer/survivor case managers are as effective as non-consumer/survivor case managers in providing services (Solomon, 1992).

In addition, consumers/survivors have begun conducting research themselves. Among their initiatives are an evaluation project directed by Judi Chamberlin at the Boston University Center for Psychiatric Rehabilitation and the newly emerging Consumer/Survivor Work Group on Policy and Research.

Mental health consumer/survivor-operated self-help programs interact with the traditional professional system in a variety of different ways (Emerick, 1990; Boltz, 1992; National Association of State Mental Health Program Directors, 1989; Kaufmann and Freund., 1988). Some self-help programs form partner-ships with other agencies, while others retain an independent stance and so do not participate in outside collaboration. The Center for Self-help Research is investigating this area to raise the specific issues involved in forging interorganizational relationships (Hasenfeld and Gidron, 1992).

Consumer/survivor organizations are also increasing their efforts to work with one another. The development of national and, in particular, Statewide organizations have played a role in encouraging consumer/survivor-operated programs to develop linkages with each other. However, on the national level, political differences have created divisiveness among different factions of the movement. While some observers have argued that this is the type of healthy political discourse found in any movement, others have seen these divisions as destructive to the sense of unity needed to accomplish common goals. State-wide organizations, on the other hand, have made great strides in bringing various independent consumer/survivor-operated programs together to work collectively for positive change and for the further development of consumer/survivor services.

From this overview of the literature, it is clear that there is much more to be learned about the phenomenon of mental health consumer/survivor-operated self-help services. The following chapters of this report examine the results of the 13 CSP Consumer/Survivor-Operated Services Demonstration Projects as the first step in enlarging understanding about the consumer/survivor-operated program model. The descriptions of all 13 individual projects presented in Chapter 2 illuminate project similarities and differences. Chapter 3 offers a cross-site analysis as well as practical, program-level suggestions and policy recommendations based on those findings.

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