Several years ago, Doug Dornan went to his psychiatrist with a list of 10 symptoms of hypomania that he had observed in his own behavior and asked for an increase in medication. The doctor refused. A few weeks later, Mr. Dornan was hospitalized with mania. He told his new doctor that he had responded well in the past to lithium or Depakote; the doctor prescribed Thorazine. Mr. Dornan refused.

A month or so later when his insurance ran out, Mr. Dornan was converted from voluntary to involuntary status and transferred from a private hospital to a state psychiatric facility. The state hospital psychiatrist wanted to try him on Risperdal. Citing research evidence that he said showed Risperdal to be effective primarily for schizophrenia, not bipolar disorder, Mr. Dornan again requested lithium or Depakote. Once again, he said, the doctor refused to take his concerns seriously. A stand-off resulted: for three weeks, neither side would budge. Finally, Dornan’s daughter and a close friend had reached their limit. “Take the damn medication. It doesn’t matter if you’re right or wrong. It’s your only ticket out of here,” he recalls them saying in exasperation. Five days later, Mr. Dornan left the hospital—on Risperdal.

Unfortunately, that wasn’t the end of the story. According to Mr. Dornan, formerly a research scientist at the New York State Office of Mental Health and now a doctoral student and teaching assistant at the University at Albany School of Social Welfare, he plummeted into the most severe depression of his life while on Risperdal. “I had to fight my way back from a depression that took away my cognitive abilities. I had always been uni-polar before; now I was suicidal,” Mr. Dornan says. “I think the severity of the depression was related to the fact that I was manic for over three months while we argued about medications.”

Mr. Dornan eventually found a part-time job and worked his way into his position at the state Office of Mental Health, but it was a long recovery process. Could there have been a different resolution? “If I had been able to trust and be trusted, if any one of the doctors treating me had respected my knowledge about my own history and treated me as a partner, the whole course of things could have been different,” he says.

Trying ADR Techniques

In the past few years, people have begun to apply principles and techniques from the field of conflict management to problems such as Mr. Dornan’s. Alternative dispute resolution (ADR) techniques—including mediation, negotiation, facilitation, conciliation and dialogue—have been used for some time in a wide variety of settings. Most states operate community dispute resolution centers where persons can receive help in solving conflicts without going to court, and many schools have instituted peer mediation programs in which students learn to handle disagreements without resorting to verbal abuse or physical violence. However, applications of ADR within the mental health system are just beginning to develop.

Mr. Dornan’s story illustrates a common problem in the mental health field, notes Laurie Curtis, co-author of a curriculum on managing conflict in mental health systems. “What’s emerging, as we listen to people, is that healing relationships are critical to recovery. In relationships, there’s always conflict,” she says. “How we handle it determines whether or not it becomes part of the healing process. Unfortunately, practitioners have confused compliance with success for so long that squelching of conflict or differences of opinion has become routine. It’s spirit-breaking.”

In preparing to design their curriculum, Ms. Curtis and her co-authors conducted focus groups and other research on conflict resolution. They found that conflict in the mental health arena looks much like conflict anywhere else. However, they came to realize that unequal power between providers and consumers in public mental health systems adds an extra dimension to the issue. “There’s an unspoken power dynamic—we play 'up the ante,’” Ms. Curtis points out. “Most mental health professionals support consumer choice—as long as everyone agrees. A case manager may be terrific at seeing the perspective of a client until there is a serious disagreement. [Then] the case manager may begin to see their job as convincing the client to follow the recommended course of action.”

Ms. Curtis emphasizes that learning about conflict management can help mental health professionals and recipients understand such concepts as “consumer-directed” services in new ways. “Some people think that consumer-directed means that clients always get their own way—even if what they want is to be taken to the grocery store at 3:00 a.m.,” she notes. “Training in conflict management helps people to see that you don’t have to fight about one specific choice—there are always other options. What really matters is how people go about sorting things out.”

Judi Higgenbotham, Human Rights Coordinator at Arizona State Hospital in Phoenix and director of a mediation program for mental health consumers at the hospital and in the community, acknowledges that physicians are sometimes reluctant to bring medication issues to the table; however, she said once mediation begins, the results are encouraging. “The greatest success of our program is with disputes about medication and treatment issues. It almost always boils down to a communication issue—the doctor or the treatment team either hasn’t listened to what the patient is saying or hasn’t explained things well,” Ms. Higgenbotham says. “In mediation the patient is given a real chance to be heard. Once doctors realize that people are not trying to usurp their power, that they just want their histories and experiences to be recognized, a solution always seems to emerge.”

Ms. Higgenbotham is convinced that the program makes a real difference in the milieu of the hospital and in patients’ lives. She too believes that one of the keys to success is leveling the playing field between patients and staff. “Sometimes the whole clinical team wants to come [to the mediation sessions]—it’s essential that you limit the numbers,” she explains. “Also, I always have the patient go first in telling their side of the story.”

Steve Golina, a patient at Arizona State Hospital who is actively involved in his own treatment, agrees. Mr. Golina had been in the hospital for a year when he first had occasion to use the mediation program. His fiancée was visiting, and the two were laughing about something in the day room—a little too loudly, according to staff, who asked his fiancée to leave and restricted further visitation. A short mediation session resulted in a contract that met all parties’ needs.

Mr. Golina says he doesn’t know what would have happened if the mediation program had not been available. “I’m incarcerated, there’s basically nothing I can do. It’s hard when you know that whatever you say or do can be used against you,” he says “And my fiancée is a very vocal, active person. We were pretty angry. Without the mediation, I don’t know how we would ever have come to a solution.”

Ms. Higgenbotham points out that mediation helps participants feel that they have some control over what happens to them and fosters a less confrontational atmosphere. Mr. Golina agrees. “Going through mediation taught me a different way of approaching problems,” he notes. “It gives you tools that instead of fighting a situation, you can focus on what you can do to fix it.”

Training Consumer, Family Mediators

Velma Beale, past president of NAMI-Ohio, and Jeanne Clement, Associate Professor of Nursing and Psychiatry at Ohio State University, have had a similarly positive experience with mediation. Since 1994 they have trained consumers and family members in cooperation with community mediators using a co-mediation model. Lana Van Voorhis, one of the consumer mediators who received this training, works for a local mental health agency using her mediation skills in a variety of settings, from the emergency room where she does crisis intervention to a local consumer-run program. Ms. Van Voorhis points out that consumers make excellent mediators in the public mental health system: “We’ve been there. We know that people sometimes feel like others are taking over their lives, and how important it is for us to do as much for ourselves as we possibly can at any point in time,” she explains.

Ohio has recently revised its patients’ rights regulations to include mediation as an option at any stage in the grievance process. Ms. Clement notes: “This is the beginning of a cultural change in the mental health field. Conflict resolution is so compatible with the recovery movement—they mesh together completely. Consumers learn to speak for themselves and have control over their lives.”

Using Mediation To Resolve ADA Disputes

Another area where mediation has been used effectively is in employment-related disputes involving the Americans with Disabilities Act (ADA). In 1991 the U.S. Equal Employment Opportunity Commission implemented a pilot project using mediation in an effort to resolve ADA issues before matters were taken to court. This mediation program became available nationwide in 1997.

“The ADA is a good law and has well-developed regulations. But people who are poor and disabled are at a real disadvantage,” says Laura Mancuso, an independent consultant and mediator based in Goleta, California, who works extensively with people who have mental disabilities. “It can sometimes take years to process a complaint and get to court. In many cases the individual involved doesn’t want to set a national precedent—they just want their problem fixed.”

Mediation has advantages for employers facing allegations of discrimination under the ADA, as well. “In my experience, employers really don’t intend to harm the person with a disability, but they may initially be reluctant to take a complaint seriously,” Ms. Mancuso notes. “On the other hand, they would much rather resolve the issue themselves than have the federal government involved or go to court. Mediation brings them to the table.”

Promoting Dialogue

Dialogue among groups with different perspectives is also proving to be effective. The federal Center for Mental Health Services has sponsored a series of dialogues between consumer/survivor/ex-patients and mental health professionals, including psychiatrists, psychologists, social workers and psychiatric nurses, according to Paolo Del Vecchio, senior policy analyst, and Carol Schauer, consumer affairs specialist, who jointly direct the program. These semi-structured discussions have helped people to move beyond their labels as consumers or professionals and have resulted in concrete recommendations, many of which have been implemented.

Last year, with California lawmakers considering outpatient commitment legislation, five state-level mental health organizations sponsored public forums to promote dialogue on this issue among stakeholders. Experienced mediators who had received additional orientation in mental health issues facilitated the events. More than 2,000 people from 46 of the state’s 58 counties participated in the forums.

According to Ms. Mancuso, who was the project coordinator, the mediators “were able to acknowledge areas of disagreement while also identifying areas of agreement. And perhaps most importantly, people were heard on the issue. One family member said afterwards that he had never realized the full impact of involuntary treatment on an individual, and that he was going to have to rethink his views on the issue.”

Andrea Blanch, Ph.D., is Director of the Collaborative for Conflict Management in Mental Health at the Florida Mental Health Institute, University of South Florida, Tampa. Dr. Blanch previously served as Associate Commissioner of the Maine Department of Mental Health, Mental Retardation and Substance Abuse Services and Director of Community Support Programs in the New York State Office of Mental Health.

A foster parent calls and demands that her 14-year-old foster child be removed from her home. She says that the youth is uncontrollable, has been staying out past bedtime and has been picked up by the police twice for curfew violations. Furthermore, she says, he talks back to her, ignores her rules, misses classes and hangs out with undesirable people. She also feels that the foster child’s caseworker has not been helpful. For his part, the foster child says he wants to live with his biological mother and feels that the foster parent is too intrusive and has too many rules.

Working with children and families is rewarding, but it can also be full of conflict and stress. It is common to witness disagreements between natural and foster parents, differences of opinion between mental health and social service workers, and arguments between caregivers and children, especially adolescents. Unresolved conflicts can result in the loss of foster home placements, burnout among workers and poor outcomes for both children and their families.

A new program in Prince George’s County, Maryland, provides mediation services in cases involving foster care, adult protective services and adoption services. Beginning in December 1999, about 25 foster care workers with the county Department of Social Services received an intensive, 40-hour training program in mediation skills offered by Advanced Dispute Resolution Systems (ADRS) of Bethesda, Md., that enables them to help parties in conflict to resolve their differences. In addition, all other county foster care workers received a one-day training designed to increase their understanding of the mediation process, to demonstrate how mediation can be used and to discuss criteria for referral to the county’s mediation program.

The program is breaking new ground, says Uma Ahluwalia, deputy director of the Prince George’s County Department of Social Services. “It’s a peer mediation model—people work on each other’s cases—and what’s neat is their success,” she explains.

Ms. Ahluwalia says that about 84 percent of cases that have gone to mediation to date have resulted in successful settlements. Outcomes have included preservation of foster care placements, better feelings about the resolution of an issue even if the placement is terminated and the development of conflict management skills on the part of all participants. Caseworkers report using mediation skills in their day-to-day interactions with consumers and to help colleagues problem solve in difficult situations.

Prince George’s County has recently extended the mediation program to other staff members including adoption caseworkers. Several nearby jurisdictions are considering adopting the model as well. This model and the county’s experience with implementing it were the subject of a presentation planned for the national meeting of the Society for Professionals in Dispute Resolution, September 14-16, 2000, in Albuquerque, New Mexico.

Webster’s Ninth New Collegiate Dictionary defines mediation as an “intervention between conflicting parties to promote reconciliation, settlement or compromise.” As the nation’s public mental health system seeks to evolve toward improved services, consumer empowerment and economic stability, there inevitably are conflicts, disagreements and tensions. Stakeholders are searching for ways to resolve these conflicts in a manner that is both effective and respectful of the rights and views of all involved.

This issue of networks provides a look at “alternative dispute resolution” (ADR) techniques that are beginning to besed to resolve conflicts in the public mental health arena. The articles provide insight into these techniques as well as concrete examples of how they are being put into practice in public mental health settings from Maine to California.

Although new to the public mental health arena, at least on a formal basis, alternative dispute resolution techniques such as mediation are a good fit for the mental health system, with their emphasis on person-to-person interaction, mutual respect and willingness to delve deeper tonderstandnderlying concerns and promote empathy among participants. As noted in the “Focus on the States” article concerning Maine’s mental health mediation program, mediation is not a prescriptive approach that imposes outcomes on participants; instead it “offers a process for people to discover their own solutions.”

Andrea Blanch, Ph.D., author of the lead article as well as the other primary articles in this issue, is well known among stakeholders throughout the public mental health system. A former Associate Commissioner of the Maine Department of Mental Health, Mental Retardation and Substance Abuse Services, Dr. Blanch is Director of the newly established Collaborative for Conflict Management in Mental Health at the Florida Mental Health Institute,niversity of South Florida, in Tampa and a pioneer in these of ADR strategies in mental health.

When discussing new techniques and technologies, it is always important to maintain a sense of balance. There is no magic bullet to solve all of the complex human, institutional and historical conflicts that arise in the public mental health arena. However, it is important to recognize alternative dispute resolution strategies as valuable additions to our tool kit as we move to a new era in the public mental health system.

— John D. Kotler, M.S.J., Senior Writer/Editor
— Paul R. Musclow, M.A., NTAC Director

Stephen W. Mayberg, Ph.D., director of the California Department of Mental Health, received the Outstanding Psychologist of the Year Award at the Annual NAMI National Conference in San Diego, California, June 12-18, 2000. In presenting the award, Darlene Prettyman, RN C, Secretary of the NAMI National Board of Directors, praised Dr. Mayberg for being “the moving force in California for direct involvement of clients and family members in the implementation of managed care systems of service throughout the state.” As a result of his leadership, Ms. Prettyman noted, consumers and family members had the opportunity to participate in key committees and decisions during the state’s implementation of managed care and to serve as paid members of the oversight teams that provided on-site review of county efforts to establish managed care. “Because of the foresight and leadership of Stephen Mayberg, persons with mental illnesses and their families are an important part of the treatment programs throughout California,” Ms. Prettyman said.

A Maine woman and her two children still have a place to live—thanks to Maine Mediation Services. Jane (not her real name) was about to be evicted from her apartment when her case manager suggested that she try mediation. Jane and her landlord could not agree on anything, from the number of pets she could have to how clean she should keep the apartment. The landlord wasncomfortable about Jane’s mental illness, and Jane was afraid she would be rehospitalized if she lost her housing. Communication between them had completely broken down. Jane, her case manager and the landlord agreed to participate in a mediation session. The result: a signed lease with conditions that satisfy both parties and better ongoing communication between Jane and her landlord.

Maine Mediation Services is a new program to help mental health consumers and others resolve disputes more effectively, whether they occur in mental health programs or in other settings. Maine has long been a leader in promoting the rights of people with mental disabilities. In 1985 the state established the “Rights of Recipients” and developed a process to ensure that people with mental disabilities who filed grievances received a fair hearing. The original emphasis was on people in inpatient facilities, but the focus has since shifted to consumers participating in community-based programs.

Although that process was valuable, it also tended to be adversarial and often left both parties dissatisfied, according to Susan Wygal, director of Adult Mental Health Services for the Maine Department of Mental Health, Mental Retardation, and Substance Abuse Services. In addition, consumer advocates reported that some people who felt they had been wronged were not bothering to file grievances because they had lost faith in the process. Seeking a more effective approach, the department issued a request for proposals in 1998 for a statewide community mediation service to handle disputes involving all populations served by the agency. The premise was that at least some disputes that would otherwise endp as formal grievances could be better resolved through mediation.

The department selected the Maine Community Mediation Coalition, a consortium of dispute resolution providers experienced in issues ranging from landlord-tenant disputes to environmental debates although not in mental health. According to Kim Vogel, the program’s original director, the lack of experience with the mental health system was not a serious obstacle. “Although we had never done outreach to this specific population before, anyone who mediates in the community has experience with people who have mental health-related problems,” Ms. Vogel notes. “The diagnosis issually less relevant than other factors contributing to the dispute.”

Nonetheless, start-up was challenging. Although the original plan envisioned a gradual phase-in of services, the program was immediately deluged with pent-up issues, often involving longstanding, seemingly intractable disputes. Many of these disputes involved numerous parties—sometimes as many as a dozen or more people—a challenge that most of the volunteer community mediators were not yet equipped to handle. During its first six months, the programnderwent significant refinements, and staff received additional training. Eventually, the program settled on a structure that includes a central intake coordinator to help clarify the nature of each conflict and refer problems elsewhere if they appearnsuitable for mediation.

According to current program director Rosemary Foster, part of the challenge has been to help participantsnderstand how mediation differs from other conflict resolution strategies. Many people who try to help others solve problems are intentionally ornintentionally directive, offering possible solutions or subtly imposing judgment. Or they function as intermediaries, negotiating between different positions. In contrast, a true mediator seeks to have the parties distance themselves from their positions and discover thenderlying reason or interest that is expressed in the position. Mediation offers a process for people to discover their own solutions.

Some of the benefits of the mediation program werenanticipated. Ms. Foster points out that through its training activities, the program has raised the awareness of nearly a hundred community mediators in Maine about mental disabilities. There are now waiting lists for mediator training in this area. Nancy Christiansen, the department’s liaison to the mediation program, points out anothernexpected benefit. “Just by having their dispute listened to, people get the idea that it is solvable, and go on to solve it themselves,” she explains. “There have been instances where the mediation session was canceled because the people ran into each other in the grocery store and worked it out. That wouldn’t have happened if they had filed a grievance.”

For more information about Maine Mediation Services, please contact Rosemary Foster, Director, at (207) 621-6848.

October 11-15: National Empowerment Center, Inc. Alternatives 2000: A New Vision of Recovery. Nashville, TN. Contact Pat Guyton at (877) 408-2401 (toll free).

October 15-17:niversity of Vermont and the American Telemedicine Association. How to Build a Telemedicine Program. Burlington, VT. Contact Christine Lash at (802) 656-5579.

October 23-24: National Association of State Mental Health Program Directors. Medical Directors 4th Annual Symposium. Philadelphia, PA. Call (703) 739-9333.

October 26: Pacific Clinics. Mental Health Summit: Health and Healing Practices for People of African Ancestry. Los Angeles, CA. Contact Blanca Carbajal or Ann-Marie Stephenson at (626) 795-8471.

October 29: Center for Mental Health Services and the American Psychiatric Association Committee on Poverty, Homelessness and Psychiatric Disorders. 52nd Institute of Psychiatric Services. Clinical Approaches to Working with Homeless, Mentally Ill Individuals: Challenges and Rewards. Philadelphia, PA. Contact Jody Zabel at (800) 444-7415.

A new national center has received funding from the William and Flora Hewlett Foundation to promote the use of alternative dispute resolution techniques in mental health and social services. The Collaborative for Conflict Management in Mental Health (CCMMH), located at theniversity of South Florida in Tampa, is a consortium of three organizations—the Florida Mental Health Institute, the National Association of State Mental Health Program Directors and Advanced Dispute Resolution Systems. The center’s mission is to contribute to the development of a public/private mental health system in which conflicts are managed in a non-coercive and non-adversarial manner. The center works at the consumer, provider, agency and system levels in the areas of product development and testing, information dissemination, skills training, consultation and technical assistance, conflict management services, and research and evaluation.

networks is published by the National Technical Assistance Center for State Mental Health Planning (NTAC) and is supportednder a Cooperative Agreement between the Center for Mental Health Services, Substance Abuse and Mental Health Services Administration (CMHS/SAMHSA), and the National Association of State Mental Health Program Directors (NASMHPD). Cited reproductions, comments and suggestions are encouraged.