New Hampshires Mental Health System:

The Role of Peer Support Agencies

Written by: Bridget E. Pearce English Composition I (Section H) Professor Simon Walsh 11/6/2010

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At what point should consumers of mental health services be made aware of all their community support systems and other alternative treatment options? The answer should be as soon as they seek any kind of professional help. Peer support and peer support crisis respite centers need to be brought to a mental health consumers attention as soon and as early as possible. However, when it comes to patients rights, mental health consumers find they are fighting at each level. These include their basic rights to appropriate and timely services, or information about alternative treatment options that are available. Poor Diagnostic Tools Access to effective and affordable treatments is one reason the mentally ill often are not treated or are under-treated (NAMI State). The lack of good diagnostic tools and understanding the exact nature of the illness is also to blame for the lack of recovery. There is no chemical or blood test for schizophrenia, bi-polar, or any other mental health illness. It is just a series of questions derived from the DSM-IV (McHugh 29). Would you diagnose cancer just by asking if someone feels a lump in their breast and assume it is cancer and take the breast? Or start chemotherapy? The answer is a flat out no, yet this is exactly what happens to those with mental illness. McHugh also believes that because of the poor diagnostic criteria many people are diagnosed with an illness that they really do not have (30). Some surveys use just the questions posed in the DSM-IV to determine if a person had, has, or may develop a mental illness (27). However, Paul Lawrence believes that our culture causes us to have a higher prevalence of mental illness (20). He believes that the studies have excluded schizophrenics and has greatly under estimated the number of people who are mentally ill (21-22). It seems that no matter how you look at the studies and how you view the criteria the fact remains that there are far too many people who have a mental illness and do not have the supports to help them cope with their illness.

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The True Cost of Untimely Care If a consumer were to call their local mental health clinic in New Hampshire, telling him or her that they are beginning to destabilize, and they want to get treatment before that happens, the consumer is most likely to hear that it will be four and a half to five months to see a psychiatrist and several weeks just to see a councilor. The in-take specialist will recommend seeing a primary care physician in the interim (Janvier). However, no mention of peer support, or other community support systems are made known to the client. As for the primary care physicians, while able to prescribe the medications needed, they are not really trained in mental health medications and treatment options; this was according to Dr. John Walters, my personal physician. He additionally stated that he was not comfortable giving me my medications due to possible side effects the medications could have on me. He knew about my past medical history, and he knew that I would probably end up being hospitalized, and not because I was weak (Staff Mental), but because as much as this is a mental illness, it is also a physical one (Introduction XXXIV). I ended up being admitted to the psychiatric ward because I was completely destabilized, and that could have been avoided in two ways: first, I needed to learn how to manage my illness; second, I needed an empathetic ear; and I needed someone that would understand why I went off my medications in the to begin with. If I had known about peer support and crisis respite systems, I could have avoided that hospitalization all together. I really did not need medications back then, nor do I now. What I needed was to learn how to handle a triggered response and that there was a safe place for me to go outside of my home environment.

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Recovery on the Horizon I would not find out about the peer support system until a month or two after that last hospitalization in 2007. I only found the peer support agency because I accidentally found a flyer on the floor of the local community mental health center: Monadnock Family Services. That day I started on my journey to recovery. Given my past history one would think I would have had some serious relapses in the last few years, and while I have come close to needing the hospital, each time I was able to remove myself from the trigger long enough to see the entire picture clearly, and once my perspective is gained, I am able divert a continued crisis response. My goal is to make sure everyone knows that: there is hope, that recovery is possible, and there are many great resources and people who will help. Peer support and crisis respite centers in New Hampshire are free: for residents (Dolan). Recovery means different things to different people. Damien said recovery meant that a person is moving toward a richer more fulfilling life, whatever that means [to them], and no longer defined by their illness. For me recovery means not requiring medications and frequent hospitalizations, and that I will have dark days and indefatigable nights, but that I will not let them control me. Empowering Consumers Many mental health consumers are not empowered by the current system (Licata). This includes the existence of additional resources and support options. Consumers are often told that medication will be a part of their lives: for the rest of their lives (Jamison 7, 102). Most consumers are not even aware that there are alternative places for support in their recovery goals. Recovery is also not a part of the mental health consumers vocabulary (NAMI Grading). This is an area we need to focus on if we are going to affect real change. Anybody can become an advocate for consumers of mental health and anyone can learn to find their own kind of recovery with the right tools, not given to them, but shown their options. That is empowerment.

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Defining an Illness Then there is the lack of a solid definition for mental illness. This is a strong part of its difficulty in understanding the idea, not to mention the difficulty it causes when trying to diagnosis a person with a specific type of mental illness. How can we expect to treat a person with a known problem, if we are not even sure of its root cause? The National Alliance on Mental Illness writes that mental illnesses are medical conditions that disrupt a persons thinking, feeling, mood, ability to relate to others and daily functioning (NAMI NH Types). However, the concept of mental disorder, like many other concepts in medicine and science, lacks a consistent operational definition that covers all situations (Introduction XXX). Then again . . . the term mental disorder unfortunately implies a distinction between mental disorders and physical disorders that is a reductionistic anachronism of mind/body dualism. A compelling literature documents that there is much physical in mental and much mental in physical disorders (Introduction XXXIV). We need to find a clear and solid definition if we are really going to bring recovery to the mainstream way of thinking. We also need real diagnostic tools, so we know why and how a drug will really react within a person and not just assume it is the lack of serotonin for which we take Prozac to treat it (Johnson, 15). Services Available So lets say they think someone has a mental illness, what are the options? Most treatments and care will revolve around the community mental health center and its fee for service methodology. Lets use my own experience with the steps to getting appropriate care First there is the intake specialist, who will sit with the consumer and explain what they do. They will get a little background information, another way of saying, the consumer must tell the story of

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how they came to the center and then they may set the consumer up with a councilor or if appropriate the psychiatrist for medications, they may even setup an appointment with the famed case manager. At some point the social worker may mention NAMI in its acronymic form (National Alliance for Mental Illness), it is not explained who and what they are, and consumers are made to feel it is yet another large organization that cannot benefit them. Local PSAs rarely get mentioned and if they do it is more in passing (Licata).Peer support was never brought to my attention. Overcoming the odds Monadnock Family Services, a local community mental health center (CMHC), has over 700 consumers (Dobisky), and the local peer support agency, Granite State Monarchs (GSM), have just about 200 consumers (Licata). This says a few things. Maybe consumers are told about the PSA, but are not told how they work; what they do, and what it is really like at the PSA. Maybe they dont feel it is right for them, and they could be under 18, as PSAs are only for adults. It could also be that it never gets mentioned. We need to equalize these numbers. Because peer support centers are free, and offer group support for various illnesses, with trained Intentional Peer Support (Mead, IPS) staff, who also are psychiatric survivors, and on their recovery path, it can be a real benefit to the consumer who feels alone. It is peers helping peers through mutuality (Licata, IPS). We Can Change the System Another barrier to proper treatment are the health care providers themselves: they do not feel people with mental illness are deserving of the same treatment as patients with other illnesses, and should be forced to receive services that they do not want, often using coercion to

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force their position. If you do not comply, you will not receive medications, or you will be committed to the state mental hospital. This unfortunately is not just found in a simple document, but through my own personal experiences, that would be later substantiated in the New Hampshire Department of Health and Human Services findings in a very recent audit of Monadnock Family Services. The audit was sparked in part by a recent report that I gave before the U.S. Department of Health and Human Services: Substance Abuse and Mental Health Services Administration conference in Boston, and then again before the NH Mental Health Consumer Council. Marty Fuller, director of the Office of Consumer and Family Affairs, spoke with me last spring after one of these council meetings about my report. She was concerned about my experiences with the mental health system. The investigation that ensued really made me feel that a single person can make a difference in the mental health system. MFS no longer forces consumers to have case management and a councilor/therapist in order to receive psychiatric medications (Dobisky). This is a very welcomed change, and because of this I may go back to MFS. Stigma from the Unexpected and Coercion Tactics All in the Name of Treatment Another factor in a patients right to receive appropriate care comes from the stigma and the connotation people often form about a person who is mentally ill. Surprisingly, it is from the people whom we are supposed to respect and trust that make our lives the most difficult to bear. Doctors still do not believe in recovery and moreover people who have a mental illness should not bear children (Jamison 190-192). I remember back in 1999, when I was still recovering from a triggered stress response, the threat of losing my two children because of my mental illness made me further fear the system that was supposed to help me. If you do not take this medication, or take this treatment, I will have no choice but to call the Department of Social

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Services. Though I knew I would be out cold for days at a time, I did as the doctor said. It was not until the third day of the medications when he came to check on me that he realized how right I was, and the medication was stopped. However, there are many people who could not live without their medications. Denise Ross is one such person. She was talking with me before the conference in Boston last year and told me how great her experience has been with her doctors and her medications and without them she would have died. She stopped eating. She had no will to live. She was taken to the New Hampshire State Hospital and committed for a couple of weeks. Kenneth Fox believes that we need to commit people like Denise more regularly. I would be a case where he would have probably taken the key and never to let me out again (50-59). Thankfully my husband saw that it was a temporary state and knew I would be well again. Fox never got to see his wife learn to manage her illness, he divorced her (56-57). I wonder if he exhausted all of his options, or if he was never made aware of his options. I called Ross to find out if her feelings have changed at all about the mental health system and the NH Hospital. The only thing that she has an issue with is the conditional discharge (CD) that are thrown onto people who end up in the state hospital, often lasting 5 years. This is the longest in the country. It is like being on probation from jail. Thomas Szasz has much the same view. He sees the system as striping patients of their civil right[s] forcing patients to have unwanted treatments preformed and medications to be forcefully administered (60-69). Ross also feels that there is abuse in the system because of these discharges. Conditional Discharges require patients to follow a strict treatment plan and that if you are re-hospitalized because of difficulties with your illness; your CD is extended again, even if you were doing everything you were supposed to be. If a cancer patient has a relapse are they treated like a child? If they do not follow their treatment plan are they subject to arrest? No, they are not, yet this is true for those with an illness affecting

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their thinking. Ross had an additional year imposed on her because she had a relapse while behaving (Ross). To me that is unacceptable. Both Denise and I utilize peer support centers and we are both advocates in New Hampshire. She takes medications and also participates fully in the local CMHC, while I utilize only the peer support system. She did not know about the crisis respite program until very recently herself. This is something she said she might use if she felt herself going in that direction. The crisis respite centers DO NOT report to the state. It is 100% confidential (Dolan). The only question is: what will happen if we tell our provider we went to this program and we have a CD. For this question I could not get an answer. And One Flew Over Now that the concept of state hospitals has been broached, do you still get an image of a terrible place? Do you think of someone who might be found in the asylum? Do you conjure images from, One Flew Over the Cuckoos Nest? In some ways the state hospital and the Brattleboro Retreat are very much like the movie to this day. In some hospitals you are treated like a child and are denied basic rights. I will mention that I was a voluntary admittance, and that I was not actively trying to harm myself, I was only afraid that I might. To be admitted I had to endure some humiliating treatment. I will not even go into the breadth of the search that I had to succumb to. I was not allowed any kind of brazier including a sports style. I was on a co-ed floor and had to walk around feeling exposed. Once you enter the door way, you are on a locked unit. You cannot leave for any reason. You are only allowed to make phone calls at specific times and you cannot watch any television that may upset another patient, this includes the evening news. So, like the movie One Flew Over the Cuckoos Nest, you have to be sure what you watch will be ok with the others. You have to earn privileges to do anything; this includes arts and crafts and eating in the cafeteria. I have never seen this so called cafeteria you are allowed to eat at. Once

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again Ross had a different experience. She was at the State Hospital and was in a lot longer than I was, so she was able to earn those privileges. I was only hospitalized for about 2 to 3 days at a time. She loved the program, but she also listened and did everything she was supposed to. She never questioned Nurse Ratchet. Am I amplifying the stigma by talking about the hospital like this? Probably, however, I think to fully appreciate what it feels like, to a person who has never been hospitalized for mental illness, this is the best way to relate the experiences. Now lets say a consumer chooses to go to the New Hampshire State Hospital, there is a good chance a bed will not even be available. One patient had to wait in the ER for 3 days before a bed became available (Timmins Mentally). This is another way to see crisis respite, we can take patients who are able to take care of themselves and have had their medications stabilized, but are not quite ready to go home yet, or maybe they are having trouble finding suitable housing. This is a great interim place and avoids sending patients to jail as they are doing now (Timmins Concord). Another factor in this tangled mess is the lack of in-patient beds at the state hospital for children and the lack of appropriate staff to take care of them. They have children who cannot get a safe place to be treated because of overcrowding (Gorenstein Riverbend). If more adults were able to get help before the crisis happened we could divert the recourses to the childrens unit. This is not the way to handle one of the most sensitive patient types in the medical care system. Children need to feel safe and nurtured. It is one thing to do this to an adult; it is another when it comes to kids. The Cost of NOT Utilizing Peer Support Now that you have an idea about the current state hospital and one very similar which is the Brattleboro Retreat, let me describe what Peer Support Crisis Respite is all about. Crisis respite is a non-locked unit. It is a separate bedroom attached to the peer support center. Each guest has a bathroom with shower. Cooking and cleaning up are done by the guest, but there is someone to

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help the guest if they need it. Guests can bring their own car and can come and go as they please. Adult visitors may come at anytime. The peer support respite center has no medical staff, so they are not pushing drugs; instead they help the guest assess their situation. They assist in setting up any appointments the guest may want to make with their mental health and medical providers. They sit with you and talk with you. They will go over the Wellness Recovery Action Plan (WRAP) (Copeland Wellness). The IPS staff share their personal experiences of triumphs and setbacks. It is not viewed as a mistake when you need crisis respite, but instead it is seen as a feat. The consumer has self identified a possible issue and decided to get help before it escalated. There are many different group therapies to attend, and with the New Hampshire model it is one hundred percent free to residents and only $250 per night for non-residents, compared to the cost of a bed at the hospital from one-thousand to one-thousand-five hundred a night (Dolan), crisis respite care is really quite inexpensive. In 2004 I did not have health insurance and a 3 day stay at Cheshire Medical Center was over four-thousand dollars. Massachusetts is now looking to model itself after the New Hampshires Stepping Stone Crisis Respite Center. The big question is always funding. The fee for service model, while good has significant draw backs. Medicaid and Medicare, along with most private insurances will not pay for this. However, Greg Burdwood, of the University of New Hampshire and part of the NH Behavioral Health Payment and System Reform Initiative, explained to me, that several states have changed to a Peer Support Specialist and a Managed Care system with a pay-for-performance model of care. The best change is on the horizon, as we move from the current system [which] supports dependant clients, [while] the new system should open the door to recovery. Still there are people like Christina Bruni who are opposed to the idea of crisis respite centers, because she fears the term crisis, and she believes that only a certified psychiatric rehabilitation professional can help,

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and, or treat a person with a mental illness. Bruni goes on to write, that she . . . could see the benefit of respite care if the word crisis was not used as a modifier in the same sentence. . . [and] as a place to chill out for awhile, respite care makes sense. She addresses her concerns about the cost of $250 per day and that it would be cheaper for her to visit a friend. This is because Massachusetts is not following the New Hampshire methodology. If they looked at the cost of Medicare and Medicaid, along with the un-insured and under-insured, they would see the cost benefit and either lower their fees, or make it free. Everyone I interviewed said one thing that was the same. The number of prisoners is going up in direct proportion to the decreased number of psychiatric beds. Peer Support Crisis Centers (Dolan) or Crisis Respite Beds (Dobisky) in general have been viewed as the best alternative to in patient hospitalization. I was once told during one of my in-patient stays that the reason the units are locked and we are treated as babies is because insurance companies would not pay for the care if done otherwise. We need to change the views of everyone in the medical community and especially the insurance companies as this is a far less-expensive methodology and a proven one (Dolan). In Boisverts study, clients who participated in peer-run programs showed there was a significant reduction in relapse. Peers who are also staff are great role models because they can talk about their recovery and even their relapses. As a peer they are more able to show and explain the behavior and thought patterns that should be modified to divert a potential set back. (Boisevert, 205, 207) There are some draw backs to having a PSA; they duplicate some of the services offered: like group support. They are not clinicians. They are trained in Intentional Peer Support, but they are unable to council. They are able to relate experiences instead, which is something a councilor cannot do. However, because PSAs are free for residents of New Hampshire, they are the least expensive alternative for group support. CMHCs offer group support, but at almost the

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same cost as individual counseling. If we could get the community mental health centers to work more closely with the PSAs maybe the cost could be further diminished. CMHCs say they want to work with PSAs, yet neither has any ongoing programs between the two centers. Licata states that Granite State Monarchs has been to Monadnock Family Services several times; however, due to the turn over at MFS they are unable to build a solid working relationship. Dobisky, states that PSAs like Granite State are hard to work with because they want to be autonomous and independent. To me it sounds like excuses, and the people who lose are not the agencies, but the consumers. Because MFS is a fee for service model (at the moment), if they were to bring a client into the Monarchs building once they stepped through the door the MFS employee would be unable to bill for services, even if it would benefit the client more than going for a walk, or another outing, as case managers are supposed to do. This issue was mentioned by both Licata and Dobisky as a draw back from becoming better partners. Maybe the new managed care system will fix this issue. However, MFS still lacks in community involvement and awareness. As stated by Anatal, . . . [An] area of concern revolves around the need for better coordination of care between CMHC staff and community services. In the survey: NH's Mental Health Services Are Reduced as Challenges Continue; Anatal once again finds that social isolation among adults continues to be high. (Anatal UNH) I believe part of the issue stems from the use of interns and the high turnover rate that is inherent in CMHCs. MFS now uses 7 unpaid interns to manage aspects of patient care (Eisenstadter Cuts). Though Dobisky could not say in what capacity they were employed, nor their exact method of quality assurance, he did say they were supervised and patient care comes first. Change Begins Now

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What really does not make any sense is the lack of support PSAs get from the hospitals and CMHCs. On the Cheshire Medical Centers website they list some of the supports patients use to help them, and when all those fail sometimes hospitalization is required (Cheshire Psychiatry). However, PSAs are never mentioned. When I talked to the in-take staff at MFS and asked what other options I had, they only mentioned my primary care physician as an interim source. Having to wait 4 to 5 months to see a doctor, and not even being able to just see a councilor for a couple of weeks, is enough time for a patient who is probably starting to de-stabilize, to go into a full mental health crisis. Hospitalization should only be a last resort measure, but if a person only has that one option given to them in order to get the help they need, then the most expensive option becomes the only option. This usually involves lying to the hospital staff, the consumer stating that they are either suicidal or may harm someone else in order to get the only help they think is available to them (SAMHSA New 5). People have to be told that there are more options than just clergy, friends (SAMHSA Mental), and family. There are peer support centers and peer support crisis respite centers. No one is alone in the process of mental health recovery. We must realize that stigma is first imposed on us, by us, and in order to overcome stigma we must be willing to openly and honestly talk about mental illness, and its effects on us, and our loved ones. This is not a battle to be fought alone, instead you have organizations like NAMI, SAMHSA, NH Mental Health Consumer Council, and of course the local peer support agency who should be working alongside of the community mental health center. Change starts here and now, with me, and with anyone who reads this paper!

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Works Cited Anatal, Ph.D., Peter. " UNH Institute on Disability > Projects > NH Public Mental Health Survey > 2009 Survey." UNH Institute on Disability. NH Public Mental Health Consumer

Survey Project 2009, n.d. Web. 19 Nov. 2010. <http://www.iod.unh.edu/Projects/pmhs/2009-survey.aspx>. Boisvert, Rosemary A., et al Effectiveness of a peer-support community in addiction recovery: Participation as intervention. Occupational Therapy International 15.4 (2008): 205-220. PsycINFO. EBSCO. Web. 18 Nov 2010 Bruni, Christina. "Breaking News: Peer-Run Respite Care - Schizophrenia." HealthCentral.com - Trusted, Reliable and Up To Date Health Information. SchizophreniaConnection.com , 4 Sept. 2010. Web. 26 Nov. 2010. <http://www.healthcentral.com/schizophrenia/c/120/85557/breaking-news>. Burdwood, Greg. Personal interview. 16 Nov. 2010

"Cheshire Medical Center / Dartmouth-Hitchcock Keene - Psychiatry." Cheshire Medical Center / Dartmouth-Hitchcock Keene - Home. CMC-DHK, n.d. Web. 28 Nov. 2010. <http://www.cheshire-med.com/index.php? option=com_content&task=view&id=185&Itemid=846>.

Copeland, Mary Ellen. "Wellness Recovery Action Plan Mary Ellen Copeland." Wellness Recovery Action Plan Mary Ellen Copeland. Mary Ellen Copeland, n.d. Web. 20 Nov. 2010. <http://www.mentalhealthrecovery.com/aboutwrap.php>. Dobisky, Frank. Personal interview. 15 Nov. 2010. Dolan, Jude. Phone interview. 24 Nov. 2010.

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Eisenstadter, Dave. "Cuts hit Keene agency again." Monadnock Family Services. Sentinel Staff, 4 Aug. 2010. Web. 6 Nov. 2010. <http://www.mfs.org/about-mfs/news/60-cuts-hitkeene-agency-again>. Fox ,Kenneth Richard. "The Mentally Ill Often Need Involuntary Psychiatric Treatment." Mental Illness .Ed. Mary E Williams. Detroit: Greenhaven Press, 2007. 50-59. Print. Gorenstein, Dan. "Riverbend Community Mental Health - Press Releases." Riverbend Community Mental Health. NHPR: NH Hospital Reinstates Waitlist, 27 Sept. 2010. Web. 5 Nov. 2010. <http://www.riverbendcmhc.org/index.php? option=com_content&view=category&layout=blog&id=48&Itemid=72http://>. "Introduction." Diagnostic and statistical manual of mental disorders: DSM-IV-TR.. 4th ed. Washington, DC: American Psychiatric Association, 2000. xxx-xxxiv. Print. Jamison, Kay R. An Unquiet Mind . New York: A.A. Knopf, 1995. Print. Janvier, Amy. Phone interview. 21 Nov. 2010. Johnson,Steven. Preface. Mind Wide Open. New York: Scribner, 2004. Print Lawrence, Paul D. "How Mental Illness is Prevalent in America." Mental illness . Ed. Mary E Williams. Detroit: Greenhaven Press, 2007. 20-25. Print. Licata, Damien. Personal interview. 8 Nov. 2010. "Granite State Monarchs | Wellness Recovery Action Plan." Granite State Monarchs | Home. Granite State Monarchs, n.d. Web. 20 Nov. 2010. <http://www.gsmonarchs.org/resources/wrap.html>. "Granite State Monarchs | (IPS) Intentional Peer Support." Granite State Monarchs | Home. Granite State Monarchs, n.d. Web. 20 Nov. 2010.

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http://www.gsmonarchs.org/gsmresources/peersupport.html McHugh, Paul. "The Prevalence of Mental Illness in America Has Been Exaggerated." Mental illness . Ed. Mary E Williams. Detroit: Greenhaven Press, 2007. 26-32. Print. Mead, Sherry. "(IPS) Intentional Peer Support." Granite State Monarchs | Home. http://www.mentalhealthpeers.com, n.d. Web. 20 Nov. 2010. <http://www.gsmonarchs.org/gsmresources/peersupport.html>. NAMI. "Grading the States 2009: A Report on Americas Health Care System for Adults with Serious Mental Illness from the National Alliance on Mental Illness - NAMI." NAMI: National Alliance on Mental Illness - Mental Health Support, Education and Advocacy. National Aliance of Mental Illness New Hampshire, n.d. Web. 6 Nov. 2010. <http://www.nami.org/Content/NavigationMenu/Grading_the_States_2009/Grading_the _States_20091.htm>. State Statistics: New Hampshire NAMI. National Alliance of Mental Illness. n.d. Web. 6 Nov. 2010. (1-2). <http://www.nami.org/Content/NavigationMenu/State_Advocacy/Tools_for_Leaders/Ne w_Hampshire_State_Statistics.pdf>.

NAMI NH "Advocacy." NAMI NH. National Alliance of Mental Illness New Hampshire, n.d. Web. 6 Nov. 2010. <http://www.naminh.org/index.php?page=advocacy>. Types of Mental illness NAMI NH. National Alliance of Mental Illness New Hampshire, n.d. Web. 6 Nov. 2010. <http://www.naminh.org/education/types-of-illness>. New Hampshire Department of Health and Human Services, Bureau of Behavioral Health.

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"Performance Audit: Monadnock Family Services August-September 2010." New Hampshire Department of Health and Human Services Division of Community Based Care Services Bureau of Behavioral Health August-September 2010 (2010): 3-16. Print. One Flew Over the Cuckoo's Nest. Dir. Milos Forman. Perf. Jack Nicholson, Louise Fletcher, Danny DeVito. Warner Home Video, 1975. Film. Ross, Denise. Phone interview. 6 Nov. 2010. SAMHSA. "Mental Illness: What A Difference A Friend Makes - About this initiative." Mental Illness: What A Difference A Friend Makes. Substance Abuse and Mental Health Services Administration, n.d. Web. 8 Nov. 2010. <http://www.whatadifference.samhsa.gov/site.asp?nav=nav00&content=4_0_about>. "New England Regional Consumer/Survivors Meeting." U.S. Department of Health and Human Services Substance Abuse and Mental Health Services Administration Center for Mental Health

Services New England Regional Consumer Council Survivors Meeting Boston, Massachusetts December 2009. SAMHSA: Boston, 2010. 1-14. Print. Staff, Mayo Clinic. "Mental health: Overcoming the stigma of mental illness - MayoClinic.com." Mayo Clinic Medical Information and Tools for Healthy Living - MayoClinic.com. Mayo Clinic, 29 May 2009. Web. 20 Nov. 2010. <http://www.mayoclinic.com/health/mentalhealth/MH00076/METHOD=print>. Szasz, Thomas. "Involuntary Psychiatric Treatment Is Unethical." Mental illness . Ed. Mary E Williams. Detroit: Greenhaven Press, 2007. 60-69. Print.

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Timmins, Annmarie. "Mentally ill patients must wait: State Hospital doesn't have space to meet need." Concord Monitor 20 June 2010: Web. 7 Nov. 2010 <http://www.concordmonitor.com/article/mentally-ill-patients-must-wait>