Reviewed by Lisa Dixon,* M.D., M.P.H.
Rosalynn Carter's book, Within Our Reach, is a call to proverbial arms. Carter and her able co-authors, Susan Golant and Kathryn Cade, aim to inspire their readers to fix a mental health system that falls far short of providing an acceptable level of care. Only someone with the wisdom and experience and sensitivity of Carter could take on this presidential challenge and do it so well. The volume provides a wonderfully lucid, compelling, and informed guide to the current challenges and opportunities of our mental health system. The authors render complex concepts simple and understandable. The book tackles a vast range of dimensions relevant to the improvement of mental health care. The sociology of stigma is as relevant as the neuroscience of the brain. The economics of financing services is as relevant as the psychology of hope. The book's clarity and breadth leave nobody behind.
Carter's method involves telling stories. She combines the stories of individuals with mental illness and their families along with her own personal story of pain and joy and discovery. She gives the researchers and policy makers and advocates who are developing solutions a human face as they think out loud to solve problems. Telling these individual stories certainly communicates information effectively--the reader gets the point. However, the individual stories have another more subtle and perhaps more important effect. Calls for change and action for big social problems too often create an overwhelming sense of powerlessness. A reader thinks, "How can I possibly make a difference?" Carter's brilliance reverses that powerlessness. Her stories of individuals empower the reader.
The book is roughly divided into three sections. The first section provides the foundation by defining the problem of inadequate access and quality of mental health care and setting the stage. Mrs. Carter invites the reader into her world, that of the wife of a successful politician, a former president with responsibilities for campaigning and helping to define a political agenda. We see the struggles of mental illness through her eyes--the
haunting memory of an exhausted woman returning home to a daughter with mental illness after working the night shift. The night shift allowed her to be home during the day while her husband's daytime job allowed him to be available at night.
Mrs. Carter remembers an evening when she and Jimmy turned on the television only to find that the show, Law and Order, focused on a person with mental illness who had kidnapped a little girl. Flipping the channel to watch Without a Trace led to another story of an individual with mental illness, one who had committed murder. Here we see the causes and effects of stigma and discrimination in everyday life. How do people with mental illness have a chance when the media's face of mental illness is a murderer? Mrs. Carter answers that question with stories of hope and action. The Carter Center has created a Journalism Fellowship Program specifically designed develop a cadre of journalists whose goal is to increase the public's understanding of mental illness. In Mrs. Carter's inimitable can-do style, problems generate solutions.
Within Our Reach's middle section includes chapters on specific subgroups or problems in mental health services. Care of children and the elderly each merit a full discussion. Here again, human stories illustrate information and facts. Mark, Angela, Alex and Alicia, children any of us could know, struggle with mental disorders. Help for them arrives in the form of appropriate medication, research on causes of childhood disorders, mental health services in schools, and newspaper stories that illuminate the problem for the general public. Additional chapters on the impact of disaster and trauma and on the criminalization of mental illness complete the book's middle section.
Mrs. Carter revealed her own introduction to trauma when she experienced a terrible car accident while driving her babysitter home. Her personal experience was only a prelude to scenes of international suffering observed in refugee camps in nations experiencing violent civil wars. Back home, she describes how Scott's grades fall after witnessing the shooting of his father who was an innocent bystander. These pages are hard to turn, but hope in the form of new treatments and understandings pull the reader forward.
The book concludes with two chapters that provide a roadmap for all stakeholders. Research is seeding new ideas for treatment and prevention. Mrs. Carter points out that 95% of what we now know about the brain has been learned in the last 20 years. If we can keep up that pace, the next decade should provide better psychological, psychosocial and medication treatments. Current efforts focus on reducing long-term disability of schizophrenia by testing early intervention programs, and reducing morbidity and mortality of mental illness by integrating medical and psychiatric care. And perhaps most important, while research will help tomorrow, the paradigm shift from maintenance to recovery heals today. Charles, Joel, Pat and Larry tell stories of building a rewarding life with mental illness. Mrs. Carter acknowledges that "The concept of recovery was not even dreamed possible when I first began working in mental health." (P. 144). This paradigm that individuals with mental illness introduced to the world of family members, policy-makers, advocates and researchers builds on hope, strength and respect. Mrs. Carter suggests that recovery involves participation in community life, and perhaps a home, a job or a friend.
Within our Reach is a volume for all of us. It transforms every reader into a stakeholder; every stakeholder is then validated but also challenged. It leaves each of us with a story. I met Mrs. Rosalynn Carter and we had a great conversation.
Lisa Dixon, M.D., M.P.H., is a leading research psychiatrist, the Deputy Director of Research for the Veterans Affairs (VA) Capitol Health Care Network Mental Illness Research Education and Clinical Center. She is also a Professor of Psychiatry at the University of Maryland School of Medicine. Her last contribution to MIWatch was A Personal Journey Wearing Three Hats: family, doctor and research director