the symbols and meanings of advocacy

International Journal of Law and Psychiatry, Vol. 8, pp. 1-17, 1986 0160-2527/86 $3.00 + .00 Printed in the U.S.A. All rights reserved. Copyright ~ 1985 Pergamon Press Lid

The Symbols

Neal Milner*

and Meanings of Advocacy

This article looks at the emergence of mental health advocacy as political reform. It is not an assessment of advocacy programs but rather a more sweeping, less detailed look. (For assessments of advocacy see Department of Health, Educa- tion and Welfare, 1979; American Bar Association Commission on the Mental- ly Disabled, 1979.) Over the last few years virtually every group or organization involved in mental health policy has described its activities as being advocacy on behalf of the mentally ill. These groups differed greatly from each other in terms of goals and values. How and why, then, did they all describe their programs and strategies with the same general term?

I argue that one reason for advocacy becoming so pervasive a part of the rhetoric of mental health reform is that advocacy has a powerful symbolic content. I further argue that it is this very powerful symbolic character that limits mental health policy makers from seeing some key differences that are crucial to the dynamics of mental health advocacy. The last sections of the article elaborate upon the conflicts in advocacy.

Advocacy as Symbol and Myth

Murray Edelman's (1967, 1977) important work on political symbolism stresses the role that symbols play in inducing the emotions that are so much a part of politics. Political acts evoke condensation symbols that in turn evoke quiescence or arousal (Edelman, 1967). Those symbols reassure that something is being done about a problem. Symbols emphasizing homogeneity and unity of purpose are especially powerful. The symbolic strength of advocacy can be seen in these terms.

The usual explanation of the rise in mental health rights focuses upon the availability of legal resources. According to this approach, there were, as a result of the civil rights movement, resources (lawyers) available to deal with mental health rights. These lawyers had experience in fields that made it easy for them to make analogies to the problems of institutionalized mental patients (Pfohl, 1975). The availability of resources was indeed one very important factor in rights emergence, but other, more symbolic forces help to explain the strength of the commitment to advocacy. By seeing their work in terms of advocacy, organizations that previously had held a rather paternalistic view of mental patients could

This material is based upon work supported by the National Science Foundation under Grant No. SES-8026590. For reports on this study, see Buker, Cuaresma-Primm, & Milner, N. D.: and Milner, 1982, 1983b, 1984.

*Professor of Political Science, University of Hawaii, Honolulu, HI 96822. U.S.A.

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reassure themselves that they were now addressing themselves to the newly defined, serious problems in mental health. Not surprisingly, organizations in which litigation predominated, like the Mental Health Law Project and the American Bar Association's Commission on the Mentally Disabled (ABA Commission on the Mentally Disabled, 1979) discussed their activities in terms of advocacy, but so did many other organizations that were frequently at odds with a rights approach to mental health policy.

For instance, the rapidly rising national Alliance of Families of Mental Pa- tients has seen its work as advocacy on behalf of the mentally ill both inside and outside the institutions (Shelter, 1979; Williams & Shelter, 1978). Yet the Alliance, along with its loosely affiliated local organizations, has frequently opposed legal rights-oriented groups, especially when such groups worked in behalf of a right- to-refuse treatment or a toughening of commitment procedures. Organizations of families of schizophrenics were not trying to make it harder to commit their children. They were advocating laws for easier commitment in behalf of their mentally ill friends and relatives. In contrast, one of the founders of the Elizabeth Stone House, an alternative community for women who have been institutionalized, says that women at the house "pursue advocacy" (Raffini, 1975). The Elizabeth Stone group has been very much influenced by mental patient liberation and women's liberation ideas, which are very often in direct opposition to the parents' groups. The national Mental Health Association, which historically had been strongly supportive of professional psychiatry, also redefined its mission in terms of advocacy. It saw itself as "the nation's largest consumer advocacy organization for mental health . . . . " (National Commission on the Insanity Defense, 1983, p. 1).

All these organizations were conceptualizing their approach to mental health reforms in language consistent with the dominant political ideology of the 1960s and 1970s. Stuart Scheingold (1974) calls this ideology the myth of rights. Ac- cording to that myth, legal advocacy is the most effective way to carry out social change, and political change can be most effectively brought about by changes in legal rules. Litigation is the linchpin. The myth further assumes that rights can be created and effectively vindicated through courts. There is little question about the power of this ideology. The political heroes of the past two decades were those advocating on behalf of someone, usually in a court of law. Those on whose behalf the advocates were acting came to be seen as people with enough dignity and rationality to have rights but with insufficient skills to represent themselves.

From the symbolic perspective, the litigation aspects of the myth of rights are less important than the advocacy aspects. Indeed groups that were very critical of mental health litigation nonetheless considered their own work to be advocacy. As we shall see in some detail, time and again the argument was made that you do not have to be a lawyer to be an advocate because advocacy transcends litigation. Advocacy is a way of life. Advocacy encouraged political arousal on the part of those involved in mental health by suggesting an appealing method of responding to a wide range of problems even if, perhaps especially if, the problems were inchoate or impossible to confront successfully. Advocacy was appealing because it offered those in the mental health field a process that, on the basis of the dominant ideology, was not problematical.

Advocacy's symbolic potency was made more powerful by the ease with which

SYMBOLS AND MEANINGS OF ADVOCACY 3

it fit into diverse and contradictory organizational goals. Organizations with opposing views on the role of mental health rights, on the ability of institutionalized people to make informed judgments, and on the discretion of the mental health professional all described much of their work as advocacy. Advocacy had a strong aura of consensus about it. For example, a Massachusetts Blue Ribbon Com- mission, which was trying to build a policy consensus on mental health reform, built this consensus very much on the issue of advocacy (Blue Ribbon Commis- sion, 1981). The Commission spent little time delineating the meaning of advocacy. The mere use of the term appeared to foster consensus and to legitimate activities. The term "advocacy" has become so encompassing that the term "advocacy groups" has been used without description as a short cut to describe a wide range of groups interested in changes in mental health policy (e.g., Whithorn, 1982).

This use of advocacy as a code word was accompanied by a view of history that stressed advocacy's historical pervasiveness and the consensus over its meaning. In an introduction to a work on advocacy for the aged, Kerschner (1976) described advocacy as:

a time-honored process in the United States. From the Native-American who stepped forth at the Pilgrims' harvest to the Gray Panthers pay- ing a house call on the American Medical Association, advocacy has been present as a indicator of that side of man's nature known as selfish benevolence. (p. xi)

This view implicitly downgrades the importance of differences over goals and implies that the process and meaning of advocacy varies little over time. Homo- geneity and unity dominate this perspective.

This exaggeration of common purpose is also a very important part of symbolic politics. Edelman (1967) describes this part of the process as ritualization, a motor activity that involves its participants symbolically in a common enter- prise by compellingly calling attention to their relatedness and joint interests. The ritualization of advocacy has been most apparent in psychiatry's attempt to influence the advocacy movement. This ritualization has stressed common goals and the unity of interests. As the psychiatrist Milton Greenblatt (1979) put it, "With the common goal of quality care, rights of both patients and staff can be sustained" (p. 67).

Nowhere is this ritualization more apparent than in the National Institute of Mental Health's attempt to develop advocacy programs. Along with the American Bar Association, NIMH took the lead in trying to foster such programs during the 1970s. NIMH, however, had a rather difficult constituency to work with because many psychiatrists felt severely threatened by the emergence of mental health rights. The NIMH publication, Mental Health Advocacy: An Emerging Force in Consumer's Rights, is the best indicator of ritualization. There, Ber- tram Brown, NIMH's director, claimed that "advocacy, in its legal and non-legal approaches, seeks to advance the right of every citizen to high quality, appropriate, and readily available mental health care" (Kopolow & Bloom, 1977, p. 1). Dr. Louis Kopolow, the NIMH psychiatrist in charge of its advocacy activities was more explicit in his attempts to use advocacy as a symbol of consensus. "Present-day connotations of conflict or antagonism," he argued (Kopolow

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& Bloom, 1977, p. vii) "is not inherent in the basic concept of advocacy, but rather results from the manner in which some advocates pursue their duties." If tensions existed, it was not because goals conflict or because there are important differences regarding the meaning of advocacy. The problem is one of style.

This approach minimized the possibility that there was serious endemic conflict between advocacy by lawyers and advocacy by psychiatrists or between advocacy by professionals and advocacy by the mental patients themselves. In Kopo- low's view, one form of advocacy complemented the other. "After pure legal rights have been established and attorneys available to patients to ensure their protec- tion, other issues remain that cannot and should not be resolved through the legal system" (Kopolow, 1979a, p. 20). The thrust of the NIMH strategy was to show how advocacy can be a cooperative venture and how both psychiatrists and other advocates must become more sensitive to each others' views as well as those of nonprofessionals working in the field.

Another indicator of symbolic content is that such groups used the term with little if any description of what advocacy means. Advocacy was seldom examined with enough care to elucidate conflicts and differences. For example, the following definitions of advocacy appeared during the same year. One defined advocacy as "acting as though one were the person for whom one advocates" (Coye & Thomas, 1979). The other said that advocacy was "to plead in favor of, support" (Moberg & Pone, 1979; Compare with Department of Health, Education and Welfare, 1979). The first meaning stresses the primacy of the interest on whose behalf of advocate acts. The second implies that such interests are not primary; the advocate might decide what the client's best interests are. That is a fundamental difference, yet both are called advocacy, and those considering themselves advocates typically have not discussed these differences or their implications.

Our interviews and review of the advocacy literature indicate that advocates have not been very self-conscious about the key question here, how to determine interests. The interview schedule included some questions about how they as advocates decided on the validity of an individual's claim that he or she did not want to take any more medication. Most respondents were genuinely puzzled by the question. They indicated that they had never thought much about it. Literature prepared by legal advocates (e.g., Boulder Legal Services, 1979; Scott, 1977) offers some guides of what lawyers should look for in interviewing an institutionalized person. They suggest an emphasis on the client's wishes but say little about the difficulties in determining these wishes. In his discussion of lawyer- client relationships, Scheingold 0974) mentions some of the relevant issues. There is, however, no close study of how advocates and clients interact. Such a study, which probably should be done by participant observation, would add much to our knowledge about advocacy generally.

Advocacy was so appealing a symbol because it minimized conflict yet aroused political action. Advocacy symbolized unity and homgeneity in tackling a serious issue. What emerged was a myth that mental health politics was a cooperative endeavor.

Following Scheingold and Edelman one more step, I argue that there developed a myth of advocacy. According to Edelman (1967), a myth is a set of ideas that is widely taught and believed without serious attempts at verification. Such a myth purged advocacy of its ideological content. Advocacy was viewed as a unifying rather than a divisive political tactic. The history of its use was seen as one of


the consensus rather than conflict. Though there may be differences over advocacy's meaning and conflicts over advocacy's use, these conflicts are, according to the myth, only aberrations - differences of style that can be alleviated by better people or better understanding.

Like all myths, this one had important consequences even if the consequences were not anticipated. First, the myth minimized questions of participation. If advocacy is such an easily encompassing and accommodating process, then it is of course easy to accommodate all those who would like to advocate. Con- comitantly, the myth deemphasized issues of conflict among professionals or between professionals and lay persons. One might argue that the myth was so powerful precisely because the threat of such a conflict appeared so great. Finally, the myth led one away from considering the dynamics of advocacy, the actual ways advocates and those they represent interact. Since homogeneity and unity dominated the myth, there was little concern for the complexities of the relationship between advocate and client.

In the remainder of the paper I will look at some of these things that the myth of advocacy deemphasizes or ignores. I will first show how advocacy has developed in a much more conflicting and problematical way than the myth suggests. As an analogy, I will use the field of planning because it, too, has had an advocacy movement and because the literature on advocacy planning has paid closer attention to the issues I want to raise than has other advocacy literature, including mental health. Next I will show how in fact these alternative views of advocacy have occupied the thinking and the tactics of those who are often dismissed as being interlopers and radicals on the fringes of the mental health field. I will show how views of mental health advocacy in fact differed quite dramatically and how these differences are related, not to any temporary personality conflicts, but rather to basic and important ideological differences. Finally I will suggest some generalizations about the way advocacy develops.

Alternative Views of Advocacy

The Experiences of Advocacy Planning: How the Language of Advocacy Masks Both Professional Control and Political Dissensus

Of all the advocacy movements arising during the last twenty years, advocacy planning has been the most self-conscious about its mission. It offers a useful parallel for the study of mental health advocacy. By taking a brief look at the development of advocacy planning, we can begin to see how problematical the previously discussed myth of advocacy is.

Like some other advocacy movements, advocacy planning originated during the optimistic and, for professionals, introspective period of the War on Pover- ty. Planners, like other professionals, became increasingly concerned about who had access to their services. Shouldn't those who lacked sufficient power or money to get access to planners be able to make use of what planners had to offer? The answer by those who came to be known as advocacy planners was a definite "yes," but the basis of their answer stressed professional expertise more than ways to broaden political participation.

Davidoff (1965), one of the pioneering advocacy planners, defended advocacy in terms of the "unique contribution planning can make: understanding the func-

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tional aspects of the city and recommending appropriate future action to improve the urban condition" (p. 31). How is this expertise reconciled with lay participation in planning? Reconciliation was not seen as much of a problem. Davidoff (1965) argued that the planners should try to represent groups previously denied their services. An advocacy planner should search out groups whose ideas were consistent with those of the planner. The advocate planner should then do "what he deems proper." This approach paid little attention to a central issue of advocacy, the process by which client interests are meshed with the interests of the experts. How are conflicts between client and professional to be reconciled? What about those groups whose ideas do not mesh with planners' ideas?

Though advocacy planning was an attempt to break with professional planning's traditional view that the public interest can be determined scientifically rather than politically, in fact the break was not a very clean one (Heskin, 1980). Advocacy planners claimed that advocacy was a manifestation of political choice rather than a result of scientific thinking, but a strong tinge of the scientific remained, and the political participation that advocacy planning encouraged was limited and highly structured. Davidoff's (1965) view of what he called the "idealized political process" (p. 32) showed how scientific thinking and professional dominance remained at the core of professional reform:

The idealized political process in a democracy serves the search for truth in much the same manner as due process in law. Fair notice and hear- ings, production of supporting evidence, cross examination, reasoned decisions are all means employed to arrive at a relevant truth: a just decision. Due process and two (or more) party political contention both rely heavily upon strong advocacy by a professional. The advocate represents an individual, group, or organization. He offers their position in language understandable to his client and to the decision makers he seeks to convince. (p. 32)

This ideal political process left little room for direct lay participation. The advocate became an essential intermediary between the ignorance of his/her clients and the sophistication and esoteria of the formal decision-making process. The political process in this view is one that translates political demands to questions of legal rules (compare Scheingold, 1974). This approach was no less concerned with maintaining a scientific basis of planning than the traditional approach was. The esoteric knowledge needed to make this idealized process work is very much like the specialized knowledge needed for litigation. Legal expertise replaces planning expertise. In neither the old planner's view nor the new planner/advocate 's view was there room for the rough and tumble of grassroots political participation. Advocacy planning "sought to create a better science," one that allowed more interest groups to take advantage of rationality and due process by letting experts do the work (Heskin, 1980, p. 57; See Scheingold, 1974 for a critical discussion of this approach to political action).

Local groups became aware of the participation limits of advocacy planning, and, as a result, they called the new planning theories into question. These potential allies often saw professional advocates as outsiders and even as agents of social control. "Taking the poor off the streets and encouraging their participation in the planning process was not empowering them [such groups], but in fact, robbing them of their power" (Heskin, 1980, p. 59). Community groups also ques-


tioned the planners' legitimacy in other ways. These groups wanted planners to be more entrepreneurial and less planning oriented. Planners were to become community organizers. The proper role of the planner, in the opinion of such groups, was that of a liberator rather than an advocate (Heskin, 1980). Libera- tion suggests a very different kind of politics than does advocacy planning. Libera- tion politics are more militant, less hierarchical, more radically democratic, and less trusting of experts. Advocacy entailed too narrow a view on the political problems of the dispossessed.

By the 1970s, planners had become aware of these limits. Forester (1982), for example, described such planning as "liberal-advocacy planning" which tried to broaden political participation but which attributed misfortune to accidental rather than to systematic, structural, or institutional arrangements.

Even this assessment exaggerated the concern advocacy planning had with the participation issue. As Susskind (1982), a planner himself, pointed out in his critique of the former Cleveland city planner's assessment of Cleveland, Ohio's strong commitment to advocacy planning (Krumholz, 1982), the Cleveland assessment lacked any discussion of strategies for broadening participation. There was also no discussion of the dynamics of the relationship between planner-advocates and those they represented. Like many of the community groups served by advocacy planners, Susskind (1982) took the Cleveland planners to task for seeing their roles in narrow and traditional terms.

The advocacy planning movement included attempts to strengthen professional dominance. The justifications for the dominance may have changed, but the changes still supported a new and improved approach to professional control. These attempts idealized politics in such a way as to minimize tensions between professionals and those on whose behalf they are advocating. The professional- advocates' political ideology maintained a belief in highly rationalized and structured political participation.

If advocacy planning is any indication, over time the tensions between planners and these groups are not really reconciled. Instead professionals return to more traditional ways of doing things while those criticizing the professional approach also go their own way. The links between planners and the poor remain problematic.

The Development of Mental Health Advocacy

Mental health advocacy has developed along two general directions. One, which emphasized professional dominance, is the strongest and the most visible. The other, emphasizing a view of political participation and professionalization that is quite similar to that of the community groups critical of advocacy planning, has developed less systematically and less successfully.

One wing of the professionally dominated model emphasized the importance of the mental health professional, especially the psychiatrist, as advocate. Psy- chiatrists responded to events that threatened their roles. Louis E. Kopolow (1979b) the chief of patients rights and advocacy programs for NIMH, described these new, threatening political events this way:

For the first time in history, former patients are speaking out in large numbers about their unfavorable treatment in American mental institu-

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tions and are not being ignored. They are finding a receptive audience in the general public, which is also concerned about issues of quality and appropriateness of health care, and among civil liberties attorneys who have taken up the patients' rights cause with dedication and zeal. (p. 263)

Kopolow put an optimistic gloss on these events. In his opinion psychiatrists were unduly defensive and unwilling to acknowledge that profession's abuses. This defensiveness was detrimental to mental patients because it "denied patients the assistance of the one g roup that has traditionally advocated improved care for the mentally ill" (p. 263; my italics).

Advocacy thus became a rallying call for psychiatrists. It became a means by which that profession could overcome its anger and demoralization and, with some changes in attitude and organization, maintain its "traditional" advocacy role. The new role would take the access question more seriously. "What is needed is for us to adopt a more flexible attitude in dealing with our p a t i e n t s - a more cooperative and less paternalistic approach in determining priority, and most im- portantly, a willingness to hear a patient out with an open mind no matter how mistaken we might initially feel he is" (Kopolow, 1979b, p. 70). In this approach, science and professionalism still dominate. The psychiatrist continues to emphasize the medical context of a patients' problems. The medical model also still dominates, though with some variation. The psychiatrist adopts more of a change agent role. He or she becomes a more active and enlightened participant in the process that determines the patient's fate. This involves in part a political process, but the issue of how to treat a patient is not a consumer matter (Gurevitz, 1980).

This view dominated the NIMH's approach to psychiatric advocacy (Kopolow, 1977, 1979a, 1979b; Kopolow & Bloom, 1977; Sadoff & Kopolow, 1977). This approach saw the relationship between psychiatrists and institutionalized people as beneficial, therapeutic and ultimately devoid of any conflict of interests so serious that psychiatrists could not be presumed to speak in behalf of their charges. Conflict and dissension were viewed as harmful. Instead, advocacy involves a "shared concern within the mental health community" (Gurevitz, 1980, pp. 11, see also Kopolow, 1976). That approach also restricted the role of lawyers. Legal rights were useful but for psychiatric advocates the usefulness was exaggerated.

NIMH also recognized the necessity of working with others, including lawyers and lay advocates (Gurevitz, 1980; Kopolow, 1977). In fact NIMH encouraged lay advocacy. In describing its NIMH-funded program, Western Massachusetts Legal Services (1979) emphasized the advantages of such non-professionals.

Perhaps because they are not extensively trained in legal conceptualiza- tion, paralegals can present a more balanced and human approach to institutionalized persons, and are less likely to limit their focus to narrow legal problems. Moreover, paralegals are perceived as less threatening than attorneys by hospitals, thereby enabling them to be more effective negotiators of administrative problems. (p. 23)

This Western Massachusetts program was evaluated quite highly in a national evaluation (DHEW, 1979; Appendix A; other uses of law advocacy are described in Coye, 1975; Schmidt, 1975; and Van Ness & Perlin, 1975).


Despite this emphasis on lay advocacy, the Massachusetts program maintained many of the typical advocacy characteristics. The program still had a strong professional bent. The secret to successful lay advocates "depends upon thorough training and supervision by attorneys well versed in mental disability law and available to assist the advocates on larger problems affecting all persons labelled as mentally ill" (Western Massachusetts Legal Services 1979, p. 3). The advocates were useful because they could more easily accommodate themselves to medical professional views than their more professionalized colleagues could. There was an attempt to reduce conflict of interest and merge viewpoints. Finally, though the program gave a high priority to establishing patient competency, it did not give a high priority to educating mental patients to be their own advocates.

These principles of psychiatric-oriented advocacy were expanded and institutionalized by the American Psychiatric Association under the leadership of Alan Stone. Stone, who became president of the APA, played the crucial role in get- ting that organization to adopt a more militant legal posture in behalf of mainstream psychiatry's views. Stone's strategy used a double message. It casti- gated mental health lawyers for their excessive zeal, while it encouraged psychiatrists to appreciate how important legal advocates were to protect psychiatrists' views. "Here we confront a paradox that many psychiatrists do not appreciate," Dr. Stone (1979, p. 822) said. "If the American Psychiatric Association is to become an advocate for patients, then to be at all effective, we will have to hire lawyers and learn to work with them, for better or for worse." The APA institutionalized these ideas when it hired legal counsel and became active as both plain- tiff and amicus in important legal cases (Milner, 1982; Stone, 1974, 1975a, 1975b, 1977).

The other wing of the professional model has been dominated by the legal professions. It may appear strange to lump lawyers and psychiatrists under the same rubric because they have been frequently at odds over issues of mental health rights. Also, lay advocates are more important in the legal than they are in the approach dominated by psychiatrists, and legal advocates are skeptical about psychiatrists' ability to act in a patient's behalf. For the purposes of this discussion, however, it is useful to think of the professions together because both the legal and medical approach require a professional as intermediary. Legal advocacy emphasized its own highly limited form of lay participation (in this case, of course, litigation) in which direct lay participation is difficult and uncertain (Milner, 1984; Scheingold, 1974). Litigation requires a reconceptualization of demands or interests to more technical forms. In its assessment of advocacy programs, including legal advocacy, the Department of Health, Education and Welfare's Office of the Inspector General (DHEW 1979) asked "Why advocacy?" Its answer emphasized the importance of the expert as advocate:

The wealthy and the powerful have long appreciated the importance of having those with a mastery of both technical information and per- suasive speaking to protect their business and personal interests. In- deed, it is difficult to imagine a Corporation, Foundation, or Trust without its team of lawyers and experts (advocates). As daily living has become more technical and complex for ordinary citizens, there has been increased recognition of their need for such assistance also. (p. 4)

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The similarities between the legal and medical professional approaches to advocacy become more apparent when we look at the other approach to advocacy, developed out of the mental patient's liberation movement. That movement began in the early 1970s when some ex-mental patients began to organize. The movement emerged primarily in the San Francisco Bay area, New York City, Boston, Cleveland, and Philadelphia. No formal national organization has developed, but there has been an active communications network developed among these groups. This network includes a newspaper with international circulation, The Madness Network News-- which is published in Berkeley, Cal i forn ia- and an- nual national conferences.

The groups have shared a common ideology that views psychiatry as the adver- sary and oppressor of mental patients. This ideology stresses the need for political awareness on the part of those identified as mental patients. Through consciousness-raising and direct political action on issues involving their own status, mental patients or former mental patients liberate themselves (Chamberlin, 1978; Milner, 1984). The mental patient liberation movement has stressed the rights for mental patients, but has also focused on developing collectives and loosely structured, nonhierarchical, settings that would act as alternatives to psychiatrists mental institutions (Chamberlin, 1978; Milner, 1984).

Advocacy became an issue for the liberation movement because of liberation's strong concern with increasing mental patient political awareness. In the liberation perspective, the political process by which awareness begins to o c c u r - t h e crucial first step in l iberat ion-depends on mutual support among people with shared experiences in the institution. The movement's early advocacy programs were essentially for the purpose of consciousness-raising and mutual support and did not use the term advocacy to describe themselves. As one participant in the early days of this movement saw it (Spotlight on Janet Gotkin, 1980):

We never considered ourselves "advocates." We considered ourselves b r e th ren - sisters and b ro the r s - we were related by virtue of our own experiences, and we helped each other. We acted on behalf of people who were not in a position to act for themselves . . . . I felt that mental patients can best represent each others' feelings and interests because they understand each other. (p. 6)

As this description of its early history suggests, the movement was ambivalent toward professional advocacy because such professionalization of problems was contrary to liberation's goals. Janet Gotkin (1980), an active member of the movement, objected to both psychiatric and legal advocacy. "We don't want psychiatrists or lawyers or professional advocates to control our lives" (p. 6). The liberation groups distrusted psychiatrists more than lawyers. Most will not work with psychiatrists at all.

Psychiatric-oriented advocates at times recognized that this basic conflict between that profession and the liberation movement had implication for advocacy, Kopolow (1979b) talked of the liberation movement's importance in making mental patients more assertive. He went on to say, however, that "as psychiatrists, we deny the accuracy and reality of this perspective" (Kopolow, 1979b, p. 264). Instead, psychiatric advocacy must strive for better treatment. According to psychiatric advocacy, a person typically could benefit from more psychiatric in-


tervention, and advocacy should include these possibilities. Advocating for more psychiatric resources or more voluntary commitment is anathema for the liberation movement.

Liberation movement people found themselves in an awkward position regarding advocacy. The word and the concept appealed to them. Moreover, govern- ment and private agencies were making funds available for these purposes and asking them for advice. The mental patient liberation groups could not deny that what they wanted was a form of advocacy, but they were skeptical about the concept taking on a meaning consistent with liberation goals. Judi Chamberlin (1977), one of the most important figures in the movement, expressed this skep- ticism when she said that advocacy programs that assumed the mental health system is benevolent and helpful must not be supported.

Advocacy programs must carefully examine the way in which they determine the legitimacy of grievances. The last thing a patient of a potential patient needs is a person who presents himself or herself as a "advocate," but who is part of, or allied with, the powerful mental health system with which the patient must deal. (p. 23)

She worried that advocacy, which had started in the mental patient liberation movement in a communitar ian, nonhierarchical way, was succumbing to "the professional viewpoint that prevails."

Advocacy had to take on a very different meaning to be consistent with the ideology of liberation. Mental health professionals were the oppressors while advocates had to pursue a strategy that subverted this oppression. They were supposed to be a "counterforce" against the professionals. In order to circumvent the influence of these professionals, the liberation oriented advocates would have to "work in alliance with outside forces" (Hudson, 1980, p. 13).

Consequently there were very different notions of how advocates should determine their clients' interests. One view, which is closely associated with psychiatry, was unwilling to accept the institutionalized patient's statements of his or her interests at face value. While considering the patients' views and even at times encouraging such expression as good therapy, this type of advocacy emphasized the vulnerability and instability of those in mental institutions and the need to probe the subconscious and the inner life of the patient. That focus diminishes the importance of individual views.

At the opposite pole was the view that stresses the similarity between institutionalized mental patients and everyone else. This approach stresses the ability of these mental patients to speak for themselves. Liberation oriented advocacy came close to this approach, as did the actions of some lawyer-advocates who argued that those inside mental institutions must be treated the same way any other client is treated.

Even those who claimed one of the polar positions in fact operated with a more flexible, more complex approach. For example, as we previously mentioned, psychiatric advocates recognized the need for patient assertiveness. Lawyer advocacy and even liberation advocacy recognized some difficulties in simply letting the individual decide what are in his or her best interests. Lawyers try to influence the clients' definition of their own interests. The importance that libera-

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tion ideology puts on consciousness-raising is evidence that liberation groups recognized the difficulties that powerless, oppressed people face in learning to determine their interests.

The conflict between these approaches came to a head in one of the com- munities included in our study of mental patient rights emergence. A paralegal who worked for an ABA-sponsored mental health advocacy organization was fired by this organization after the mental hospital staff complained that he was subverting their authority by advising the inmates that they did not have to take medication. The para!egal was an active member of the Alliance for the Libera- tion of Mental Patients (ALMP) group in Philadelphia. Not long before his firing, he had testified that the institution could not treat anyone successfully. The local legal professionals were not spared his criticism because he attacked the lawyers working in his advocacy project as well as the local public defender for not taking action to protect the institutional inmates. The ALMP used the firing as an issue to mobilize these inmates (Lapon, 1979).

All the conflicts masked by advocacy's myths and symbols were visible here. Indeed the fact that there was such a basic conflict itself counters the myth. On one side was an approach to advocacy that stressed the use of nonprofessionals, especially expatients. These nonprofessionals set out to teach the patients how they could help themselves by freeing themselves from the institution's oppression. This approach had no room for assumptions that the institution was therapeutic. Political organizing based on the notion that the patient was essentially in conflict with the mental health professionals dominated the Alliance for the Libera- tion of Mental Patient's strategy. The medical staff, and to a greater extent the legal advocacy staff professionals, saw advocacy as a useful tool to make the disposition of sick people less arbitrary and more reasoned. The Alliance saw the situation in terms of its potential for developing political organization and political awareness. Traditional, professional advocacy was too narrow because it did not recognize these broader political implications.

It would be a mistake to generalize from this single incident and argue that all advocacy programs have contained so much rancor. Nonetheless, the Phila- delphia incident is significant because it demonstrated so clearly the very sorts of disputes one would expect from the different positions on advocacy. The battle at that institution shows that the distinctions between professional and liberation advocacy are not merely abstract; they have had real political consequences.

There have been further conflicts between legal advocacy and liberation people. Though there have been key victories by legal advocates on behalf of mental patients' rights and though liberation groups have participated in such litigation, there has been much tension between legal advocates and liberation groups, even in the successful cases. On some key cases, lawyers and psychiatrists worked together in the absence of input on the part of liberation groups. In others there was disagreement between lawyers and these groups over the role that lay persons should have in planning litigation and developing legal strategies. In an important California right-to-refuse treatment case, conflict developed when the key attorney would not take a stand in support of an issue that the mental patient groups saw as directly relevant (a referendum prohibiting the use of electro- shock) but that the lawyer saw as threatening the legal precedent he wanted to set (Milner, 1983b, 1984). Also Janet Gotkin, whose ambivalence toward professionalized advocacy was previously discussed, was removed from the Board


of the Mental Health Law Project, the leading national legal advocacy mental health organization.

Mental Health Advocacy and Advocacy Planning

Professionals have played important roles in both the planning and mental health advocacy movements. In both, the professionals argued for professional reform. In the case of advocacy planning, the planners wanted to grant more access to their services, especially for those who were not influential members of the political process. For psychiatrists who developed advocacy programs, the issue was not simply access for such people because institutionalized mental patients already had access to psychiatry. Still, the revised approach emphasized access because psychiatrists were supposed to make themselves available at more stages of the patients' disposition. The NIMH definition of the psychiatrist as the only person capable of seeing all of the patients' interests and the attempt to get more such practitioners involved politically on behalf of their patients' needs showed how this professional view of mental health advocacy tried to make psychiatry more available. Psychiatric advocates did not attempt to divorce themselves from psychiatry's traditional, scientific and medical approach to problem solving. The new advocates argued for a better use of these assumptions, a use that included more flexibility and less disdain for opposing views but an approach that also maintained traditional operating assumptions about the nature of emo- tional problems and the role of institutions and psychiatrists in treating them.

By no means has psychiatry been unified in its responses to the emergence of rights-oriented legal advocacy. The profession has developed an appreciation for the legal process (Milner, 1983a). Survey data suggest that psychiatrists are con- siderably more approving of the rights approach than are their spokespersons in the American Psychiatric Association (Kahle & Sales, 1978; Kahle, Sales, & Nagel, 1978). There are important limits to the survey, however. First, it is a general sample of psychiatrists and does not focus on those relatively few psychiatrists who are directly involved with commitment or those who work regu- larly in institutions where the bulk of the advocacy and rights issues arises. It is like polling corporation lawyers about criminal law.

More important is the fact that organized psychiatry has actively opposed much of this rights orientation. The American Psychiatric Association has increased its legal resources and has taken a more aggressive posture against some important aspects of mental patient rights, especially the right to refuse treatment. Such action has been justified as advocacy in behalf of the true needs of mental patients (Milner, 1982).

Thus two forms of accommodat ion to the legal process have emerged among spokespersons for the profession. One emphasizes the need to appreciate law's usefulness in dealing with some issues heretofore considered to be within the preserve of psychiatry. The other form stresses how law can and must be used to protect the psychiatrist's view of what is best for his or her patient. Advocacy plays a part in each of these perspectives, but the advocacy that presumes and defends dominance by the psychiatrist is most compelling among those professionals who are the most politically active as spokepersons for their profession.

The scenarios of effective advocacy envisioned by the psychiatrist advocates have resembled planning scenarios. In both cases professionally oriented advocacy

14 NEAL MILNER

worked best when conflict was minimized and when all agreed that the professionals had the best interests of those they represented at heart. The medical professional, like the advocacy planner, was the trained intermediary, who could speak the language, synthesize interests and ultimately make correct recommen- dations. The political process as idealized by the psychiatrist-advocate has not relied upon procedural due process as has the planners' ideal. Ideal politics for the psychiatrists appears to be a situation in which all parties who have an interest in an institutionalized person sit down and reason together about that person's best interests. Such process is highly consultative but ultimately very calm and rational. This approach can be expanded to include an appearance before a legislature as well as participation in a case conference. In appearing before a legislature the ideal psychiatric advocate would act as Davidoff (1965) described the ideal political process and "offer(s) their [those he or she represented] position in language understandable to his client and to the decision makers he seeks to convince" (p. 32). Legal advocates have also stressed a highly structured and rationalized process: litigation.

In one sense, this approach broadened political participation because more, previously unrepresented interests come to the fore. In another sense, however, the participation was limited because professionals still retained rather tight control over defining the problem and solution. Allowing others to offer their views was not meant to change the patterns of dominance for either advocacy planners or professionals doing mental health advocacy.

These professional advocates emerged from, and were profoundly influenced by, political forces that transcended advocacy. The issues involved political participation. For the planners, it was the War on Poverty. In mental health advocacy, it was the "rights revolution," particularly in the emergence of mental health rights. Both planners and psychiatrists found their relevance threatened by these political developments. Psychiatrists as well as planners were somewhat supportive of these political events, but each profession felt threatened by the possibility that it would lose its proper ability to speak for those in need of its services. It appears that the sense of threat was stronger for psychiatry. Psychiatrists were typically the mental patients' adversaries in mental health rights litigation. The psychiatric wing of mental health advocacy developed at least partially to channel this bitterness by having psychiatrists fight back and become advocates themselves.

Conflict over the meaning of advocacy and the role of the professional developed quite early. My brief history of advocacy planning suggested that its history was one of increasing dissension. The development of mental health advocacy has also been accompanied by such disagreement over medical and, though to a lesser extent, legal professionals' assumptions. Fundamental to mental health liberation ideology and fundamental to the liberation approach to advocacy was the view that psychiatrists are agents of social control who blunt participation rather than encourage it. In addition, these rivals for influence over advocacy programs criticized psychiatry for underestimating the participation issues. These reactions were very similar to groups' reactions to advocacy planning.

In retrospect, advocacy planners were too sanguine about political participation. Part of this optimism was based on an assumption that lay people could easily present their demands to the planner and that the planner would be the key person in stating these demands in a meaningful way. Psychiatric advocacy did not share this degree of optimism about their charges' ability to state their


own interests, so that profession's confidence in representing others was even greater than it was for their counterparts in the planning field. Consequently the critique of the psychiatry was very strong on this issue. Lawyers were more sensitive to the position that clients can state their own best interests.

It is too soon to tell whether the later stages of mental health advocacy will be similar to the later stages of advocacy planning. In planning, the dissension appeared to lead the profession away from the concerns expressed in the early days. Some of these changes were direct responses to the counterprofessional critiques, as Susskind's (1982) activities suggest. Other changes deemphasized the participation issue so that the question of political participation became much less important. Mental health advocacy has not been around long enough for us to make judgements about what might be called the post-professional critique stage. One thing seems to be clear, however. Basic tensions between professionals and liberation-oriented advocates continue to exist and the American Psychiatry Association's advocacy activities indicate a firmer drawing of the lines.

Conclusion

Here are some tentative generalizations that could be used for further analysis of advocacy movements. They might be called the stages in the advocacy development process:

1. Professionals find themselves caught in political currents that threaten professional legitimacy and try to broaden political participation.

2. Because of the symbolic power of the word "advocacy," professionals as well as others define their responses to these political events as advocacy. The myths that emerge emphasize consensus.

3. Professionals conceptualize advocacy in such a way as to maintain dominance and increase the use of that profession's services. Lay political participation is mitigated by the use of the professional as the essential intermediary between the individuals or groups with political problems and the formal policy-making process.

4. Professionals downplay the endemic tensions and uncertainties in the relationship between themselves and the people they represent in advocacy.

5. Contrary to myths perpetuated by the professionals, the advocacy movement is fraught with dissensus over questions of the role of the professional and the extent to which lay persons decide on how their problems and interest should be defined.

6. As advocacy movements progress, these opposing views are not accom- modated. Instead, professionals maintain an emphasis on professional hegemony while their critics search elsewhere for success.

There are of course many other ways to approach the advocacy question. Some, perhaps most, would deemphasize the professional and conflictual characteristics featured here. Within my perspective, there remains much to be learned. We should have a better understanding about the process by which organizations have decided that what they do and what they are trying to do is advocacy. That analysis requires a closer look at organizations' responses to the emergence of mental health rights. We should have a better idea of the operational meaning of advocacy. What in fact do advocates do? How do advocates decide what some-

16 NEAL MILNER

one's interests are? Doing such an analysis would require anthropological tech- niques like thick description and ethnography.

Finally, we need to know more about how those who consider themselves advocates act to mitigate the tensions between various views of advocacy. I have purposely emphasized conflict in my analysis because most discussions inaccurate- ly minimize its importance. Others might have allocated less time to the liberation perspective and thus further reduced emphasis on conflict. My defense is that liberation groups not only present the issue in the most graphic terms but they also raise political issues that all too often get lost in professional discussion of mental health policy.

Nonetheless, mental health politics, even for the mental patient liberation movement is often coalition politics. Elsewhere (Milner, 1984) I have shown how these groups have attempted to reconcile their views with those of a more professionalized, structured advocacy. There is a good deal more to know about this reconciliation though the evidence suggests that the attempts do not counter the patterns in the development of advocacy that I have outlined in this essay.

References

American Bar Association Commission on the Mentally Disabled. (1979). Final Report." The bar funding program. Chicago: Author.

Blue Ribbon Commission on the Future of Public Inpatient Mental Health Services in Massachusetts. (1981) Mental health and the crossroads. Boston: Blue Ribbon Commission.

Buker, E., Cuaresma-Primm, J., & Milner, N. (1982). The uneven development of mental health rights, working papers. Available from Dept. of Political Science, University of Hawaii.

Chamberlin, J. 1977 (p. 17). (1978). On our own. NY: Hawthorn. Chamberlin, J. (1979). The limits of advocacy. Advocacy Now, 1, 21. Coye, J. L. (1977). Safeguarding recipient rights in Michigan's mental health system. In Kopolow and Bloom,

Mental Health Advocacy (p. 57). Rockville, MD: NIMH. Coy, J., & Thomas, N. (1979). Intergal advocacy. Advocacy Now, 1, 92. Davidoff, P. (1%5). Advocacy and pluralism in planning, Journal of the American Institute of Planners, 31, 331. Department of Health, Education and Welfare. (1979). Mental health advocacy project: A service delivery

assessment: Technical report. Washington, DC: DHEW. Edelman, M. (1967). The symbolic uses of politics. Urbana, Illinois. Edelman, M. (1977). Political language: Words that succeed and policies that fail. New York: Academic Press. Forester, J. (1982). Planning in the face of power, American Planning Association Journal, 48, pp. 67-80. Greenblatt, M. (1979). Rights of patients and staff, Advocacy Now, 1, 66. Gurevitz, H. (1981). The mental health professional as advocate, Advocacy Now, 2, 8. Heskin, A. D. (1980). Crisis and response: A historical perspective on advocacy planning, American Planning

Association Journal, 46, pp. 50-63. Hudson, W. (1980). The mental health professional as advocate, Advocacy Now, 2, 8. Kahle, L. R., & Sales, B. D. (1978). Comments on "civic commitment", Mental Disability Law Reporter, 2, 67. Kahle, L. R., Sales, B. D., & Nagel, S. D. (1978). On unicorns blocking commitment law reform, Journal

of Psychiatry and Law, 6, 189. Kerschner, P. A. (1976). Advocacy and ace. Los Angeles: University of Southern California. Kopolow, L. (1977). Patients' rights and the psychiatrist's dilemma, Bulletin o f the American Academy of

Psychiatry and Law, 4, 197. Kopolow, L. (1979a). The challenge of patients' rights, Advocacy Now, 1, 19. Kopolow, L. EL. (1979b). Consumer demands in mental health care, Interaction Journal of Law and Psychiatry,

2, 263. Kopolow, L. E., & Bloom, H. (1977). Mental health advocacy: An emerging force in consumers' rights.

Rockville, MA: NIMH. Krumholz, N. (1982). A retrospective view of equity planning, Cleveland 1969:1979, American Planning Associa-

tion Journal 48, 163-174. Lapon, L. (1979, April). Haverford patients' rights advocate fired, then arrested for criticizing inmates' treat-


ment, Alliance fo the Liberation of Mental Patients Newsletter, Special Haverford Edition, p. 1.

Mimer, N. (1982, June). Legal mobilization, legal ideology and structural interests: The american psychiatry association develops a sense of legal competence and mobilizes accordingly. Paper presented at Law and

Society Association meetings.

Mimer, N. (1983a). Accomodating the legal process: A review of Richard Rossner’s critical issues in american psychiatry and the law, American Bar Association Research Journal, 2, 507.

Mimer, N. (1983b, June). Legal mobilization and the emergence of mental health rights litigation: A com-

parative analysis. Paper presented at Law and Society Association meetings, Denver, CO.

Mimer, N. (1984, April). The dilemmas of legal mobilization: Ideologies and strategies of mental patient libera-

tion groups. Paper presented at Western Political Science Association meetings, Sacramento, CA.

Moberg, J. & Pone, D. (1979). External advocacy, Advocacy Now, I, 92. National Commission on the Insanity Defense. (1983). Myths and realities. Arlington, VA: National Mental

Health Association.

Raffini, M. (1975). The concept and creation of the Elizabeth Stone house. Jamaica Plain, MA: Elizabeth

Stone House.

Sadoff, R., & Kopolow, L. (1977). The mental health professionals role in patient advocacy. In Kopolow and

Bloom (Eds.), Mental health advocacy: An emerging force in consumers' rights (p. 36). Rockville, MD:

NIMH.

Scheingold, S. (1974). The politics of rights. New Haven, CT: Yale University.

Schmidt, D. (1975). Advocacy through coalition-The minnesota experience. In Kopolow and Bloom, (Eds.),

Mental health advocacy: An emerging force in consumers’ rights (p. 72). Rockville, MD: NIMH.

Scott, E. P. (1977). The mental health advocacy service: A legal perspective. In Kopolow and Bloom, (Eds.),

Mental health advocacy: An emerging force in consumers’ rights (p. 43). Rockville, MD: NIMH.

Shetler, H. (1979). patient support and advocacy conferences, Advocacy Now, I, 113.

Spotlight on Janet Gotkin. (1980). Advocacy Now, 2, 3. Stone, A. A. (1974). The right to treatment and the medical establishment, Bulletin of the American Academy

of Psychiatry and the Law, 2, 159. Stone, A. A. (1975a). The commission on judicial action of the american psychiatric association: Origins and

prospects- A personal view, Bullefin of the American Academy of Psychiatry and the Law, 3, 119. Stone, A. A. (1975b). Overview: The right to treatment -comments on the law and its impact, American Journal

of Psychiatry, 132, 1125.

Stone, A. A. (1977). Decent mental health litigation: A critical perspective, American Journal of Psychiatry, 134, 273.

Stone, A. A. (1979). The myth of advocacy, Hospital and Community Psychiatry, 30, 819. Susskind, L. (1982). Comment, American Planning Association Journal, 181. Van Ness, S. C., & Perlin, M. (1975). Mental health advocacy-The New Jersey experience. In Kopolow and

Bloom, (Eds.), Mental health advocacy: An emerging force in consumers’ rights (p. 62). Rockville, MD:

NIMH.

Western Massachusetts Legal Services. (1979). Mental patients advocacy project, Northampton, MA.

Whithorn, A. (1982). The circle games: Servicesfor thepoor in massachusetts 1966-1977. Amherst, MA: Univer-

sity of Massachusetts.

Williams, R. T., & Shetler, N. H. (Eds.). (1979), September). Advocacy for persons With Chronic Mental Illness: Building a Nationwide Network. Proceedings of conference held in Madison, WI.

the symbols and meanings of advocacy

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