In our more expansive moments at the Village we believe we are part of a revolution in the way we work with people with serious mental illnesses and we are infused with a sense of mission. Recently I noticed, however, that two other medical fields, obstetrics and oncology have already substantially achieved the revolution we've envisioned. I've decided to be encouraged rather than chagrined by this discovery. They have achieved their revolutions without the aid of any dramatic technical or clinical breakthroughs. They have instead transformed their priorities, their roles and their relationships.

I believe the conceptual shift underlying this transformation was to view pregnancy and giving birth, or surviving with or dying from cancer, not only as medical problems, but as profound, life altering experiences. How the patient experienced these events became as important as how they were clinically treated. Serious mental illnesses are clearly also profound life altering experiences.

This conceptual shift has given rise to six very practical changes in both obstetrics and oncology:

1. Changed role for the patients. Education about their conditions and the treatment options and active choice (rather than compliance) by the patients has been emphasized. This is both a proactive process and an ongoing process as treatment decisions emerge. Women are given classes about the process of pregnancy and delivering and about the various interventions, including anesthesia that are available and they actually choose what they want. Similarly cancer patients are taught about cancer, surgery, radiation, and chemotherapy and make choices. There is a goal of increased self-mastery of their conditions and collaboration on a "birthing plan" or a cancer treatment course.

2. Changed roles for the doctors and other professionals. To collaborate together rather than a patient passively complying (or possibly not complying) with a doctor's orders there must be changes on both sides. The professionals must welcome, indeed foster, their patients efforts to learn about and participate actively in their treatment. The professionals became more consultants or coaches assisting patients to manage their conditions instead of managing it for them.

3. Increased use of self coping techniques. Patients have been encouraged to actively treat themselves as an adjunct to medical treatments. Lamaze breathing techniques to reduce pain are now common place and visualization techniques for treating cancer are growing in popularity.

4. Increased use of natural supports. Including family members or friends as part of the childbirth experience or hospice team is now routine. Isolating patients with only professionals around them during their most difficult times is very rarely a medical requirement.

5. Increased usage of home or home-like settings. Home births and birthing centers where patients bring their own belongings are replacing sterile delivery rooms. Home health and hospice settings are replacing hospital wards for cancer patients. The medical equipment, while still often essential, is embedded into a home like environment rather than becoming its own environment.

6. Increased use of peer support. Many pregnant women go to classes with other pregnant women and share their experiences and support each other. Cancer survivor groups and grief groups for families of people who die from cancer are common. Especially for cancer patients a sense of pride at being a "cancer survivor" has replaced a sense of shame as a result.

As I analyzed these factors I began to realize that empowerment is not just an abstract value. It is an actual set of practices. If this set of six practices is done, empowerment will be the result. Obstetrics and oncology have done them and mental health has not. Ironically, these six practices are also a pretty good description of psychosocial rehabilitation, and have already been developed for mental health. We, however, have decided that these practices are to be used after the professionals do the "real" clinical work of treating patients symptoms and "stabilizing" them rather than as practices we all participate in pervasively. Undoubtedly there were obstetricians and oncologists, surgeons and nurses, radiation therapists and social workers who needed to be dragged into this revolution, but if they did it, so can we.

Before I yell "charge" and run off with a banner waving, I need to acknowledge two serious problems we have that oncology and obstetrics do not have. Firstly, historically we have a massive power struggle and antagonism between psychiatric patients and professionals, not a collaboration. Most of the developments in psychiatric empowerment and psychosocial rehabilitation have come from a consumer movement that is often passionately anti-psychiatry. Psychiatric "survivors" are not survivors of their illness, like cancer survivors, they are survivors of their treatments, survivors of us. The first psychosocial rehabilitation program I ever worked in, L.A. Men's Place in Skid Row, barely let me in as the first psychiatrist ever to be there. Even a psychiatrist I know who is open about having a psychotic illness was not welcome to work in his local rehabilitation program for fear he would ruin it and turn it into a clinic. The atmosphere at the yearly consumer run Alternatives Conference is a civil rights atmosphere fueled by anger at "the system". People I work with who have serious mental illnesses picketed at the American Psychiatric Association Annual Meeting. This tradition of anti-psychiatry anger will be difficult to overcome to achieve collaboration.

On the other hand, mental health professionals have an amazing tradition of coercion. We have an army of clinical language (lack of insight, poor judgment, treatment resistance, noncompliance, sabotaging, incompetent to make decisions, irrational, inappropriate, etc.) to use to take power from people. Los Angeles has an entire busy court house devoted to legally forcing people to have professionally dictated psychiatric treatment. Certainly numerous pregnant women and cancer patients make poor decisions, even life endangering decisions, about their conditions, but there is no active legal machinery for forcing them to do what we think is best. Half of the people in the public mental health system entered it involuntarily and most hospitals beds are on locked wards. Many professions seem to look back longingly on a time when they could more easily force patients to be taken care of. This tradition of coercive treatment will be difficult to overcome to achieve collaboration.

We are at much higher risk for a conflictual destructive revolution than obstetrics and oncology were.

Secondly, unlike pregnancy that lasts 9 months (although parenting lasts much longer) or even cancer that usually either leads to death or "prolonged remission" after an arbitrary standard of 5 years, serious mental illnesses of all kinds often go on much longer, even for entire lives. It is much easier to have a short term collaborative, profound experience than a life long one. (no, I didn't mean marriages. I meant treatment relationships). Continuity of care is incredibly difficult to achieve either from an emotional point of view or a system's point of view, and yet it is essential.

One of my supervisors years ago said that he'd repeatedly seen staff that had great hope and enthusiasm working with a person with serious mental illness become discouraged and angry when that person continued to be seriously mentally ill. One of our staff aptly titled a presentation "Persisting with the persistently Mentally Ill". We get burnt out and tired of the same problems recurring and progressively withdraw. On the other side, people who do poorly with mental illness grow frustrated and often begin blaming their medications or treatment or hospitalizations for their poor outcomes rather than their illnesses. They'll often abandon whatever benefit we are providing increasing our frustrations as well even people who do well with mental illnesses regularly want to leave treatment behind without incorporating self-management of their illness into their lives and deteriorate as a result. Rarely are these emotional conflicts and frustrations dealt with openly as by two equals trying to improve life. (Maybe my marriage analogy wasn't that far off and could give us some new ideas of how to do this.)

From a system's point of view, long term integrated service agencies that stay with someone regardless of their circumstances for years are vastly preferable to segmented services in a "spectrum of care". For example most of the recent suicides after discharge from a local hospital were "lost to follow up". No one had continued a treatment relationship with them and they died. Using teams helps as well because the emotional care of the team's relationship with a person can be maintained even if the individual staff leave. (This is more personal than so-called institutional connections that we rely on now. Many people describe how an institution treated them with little personal connection to any actual person there, but something seems to be missing to me when they collaborate with an institution rather than a person). Even at best, however, many people's mental illnesses predated their present treatment professionals and will continue well beyond them, and our revolution must plan for that as part of their experiences. People need to achieve substantial self management of their illnesses and community based interdependency to achieve long term recovery.

Both of these unique problems - the history of antagonism and coercion, and the prolonged nature of serious mental illnesses - can be worked with, but not from our present medical model point of view. Empowerment, and the difficult collaborative work needed to achieve it, can overcome these problems and help us achieve better experiences for people with mental illnesses. The work needs to take place on a practical level, an emotional level, a system's level and a public level. Now can I yell "charge"?