State Mental Health Policy: Promoting Legislation and Public Policy Debates in State Legislatures: A Psychiatrist's Perspective

The New Hampshire Psychiatric Society is a small district branch of APA. We have 160 members and represent 60% of the psychiatrists throughout New Hampshire. The New Hampshire legislature is unique in that it consists of 24 senators and 400 representatives. It is the third-largest parliamentary body in the English-speaking world; only the United States Congress and Britain's Parliament are larger. The New Hampshire legislature is truly a people's legislature, and meeting with the key people involved in making important legislative decisions is extremely labor intensive.

The New Hampshire Psychiatric Society has had a significant impact on various bills presented to the New Hampshire legislature over the past few years. Scope-of-practice issues have been at the forefront, with psychologists attempting to attain prescribing privileges ( 1 ). All attempts thus far have been defeated. Bills were put forward to eliminate electroconvulsive therapy as a treatment option for certain patient populations, to severely limit prescribing psychotropic medications to children, to make treatment of patients admitted to the state hospital increasingly difficult and cumbersome, and to require state hospital personnel to contact the local police department whenever any patient was discharged from the state psychiatric hospital. All of these bills were defeated. Other bills were passed and became law, the most important one being a revision of the 1994 New Hampshire Parity bill, which allows for expanded coverage for patients with substance abuse, posttraumatic stress disorder, and eating disorders ( 2 ).

Achieving success with legislative initiatives is time consuming, and as a number of us have become increasingly involved in representing our patients and profession, we have developed a clearer understanding of what makes for good—and bad—advocacy. Experience is the best teacher, and by spending time with legislators, constituent groups, and lobbyists, we have mastered several important strategies for effective advocacy.

First, advocating psychiatrists need to be informed about their issues and present their case succinctly, passionately, and without excessive medical terminology. People will not necessarily ask for clarification (no one wants to look ignorant), and advocates may inadvertently confuse legislators and lose an opportunity to make a solid case for the position being advanced.

Psychiatrists also need to partner with an excellent lobbyist, one who has been working with legislators for some time and is respected by them. This is of utmost importance, because a well-respected lobbyist will be able to get access to key legislators when needed.

Psychiatrists are also advised to gather a core group of individuals within the district branch who are willing to devote the time and energy necessary to pursue legislative agendas that will influence the care of mentally ill citizens in their state. Ideally, most of these individuals will be situated close to the state capital. Legislative committee and subcommittee hearings are sometimes scheduled precipitously, leaving little time to rearrange schedules. Being geographically close to where hearings are held is advantageous.

Psychiatrists are advised to learn to work with the media. Local media reporters can be engaged to provide information to the public regarding mental health issues and increase media coverage for our profession ( 3 ).

Advocating psychiatrists should realize that to legislators, psychiatrists are the experts regarding mental illness, its treatment, and mental health issues. At the same time, advocates should realize that they are in legislators' "court" and that legislators are the experts regarding the passing of legislation and rules. Psychiatrists must follow their guidelines when meeting with them. Psychiatrists have no special cachet with legislators, but as advocates we have an opportunity to educate legislators and be a resource to them.

Advocating psychiatrists should do their homework regarding the issues they will be discussing with legislators, keep meetings brief, and answer all questions. If advocates do not know the answer to a question, it's best to say so and assure the legislators of a prompt follow-up—and then do it. Nothing damages credibility more than not following up on promises made.

It is important not to assume that legislators will know anything about the issues they are meeting with advocating psychiatrists to discuss. After all, why should they? They have hundreds of demands on their time. Advocates need to create opportunities for education, clarification, and dialogue, and an assertive, not arrogant, approach will serve best.

A good advocate will get to know the key legislators in key committees, as well as the house and senate leadership. Advocates should attempt to meet with these leaders when crucial issues are not at stake. Doing so allows time to develop a sense of collaboration so that the relationship is not perceived as one-way.

Advocating psychiatrists make themselves accessible for questions. They present themselves as a sounding board for anything related to mental health policy. They give freely of their time and energy.

Advocating psychiatrists should work to strengthen connections with constituent groups that share their point of view. We should listen to constituents' advice and coordinate work with them on various issues—issues that may not be most important for advancing the mental health agenda but that may lead to assistance from constituents in the future, when important bills affecting mental health care come up.

Advocates need to build a strong alliance with their state medical society. Its input and support are vital in all aspects of legislation and public policy initiatives.

A strong working relationship with APA is essential. APA, through its Division of Government Relations (www.psych.org), provides a wealth of information and support to all members and district branches that are coping with legislative and public policy issues.

Patience is a virtue. The legislative process may seem painfully slow, but nevertheless the work gets done. Important bills should be monitored frequently for progress. State legislative Web sites provide an important resource for monitoring individual bills that advocates are targeting for passage or defeat. These sites usually provide first-hand information about hearing schedules.

Advocating psychiatrists may want to develop a state district branch Web site. Such sites will allow information to be rapidly disseminated to members regarding important legislative and public policy issues that need immediate attention. The site can be linked to the state legislative Web site to allow members to contact their legislators promptly whenever a vote comes up on an important bill.

Think locally. When members contact legislators, advocating psychiatrists can remind members to be clear that they are one of the legislator's constituents. Legislators listen carefully to people they directly represent. Contact from an individual from another legislative district helps but is generally less effective.

Advocating psychiatrists can expect to begin developing alliances anew every two years. Elections come and go, as do representatives, senators, and governors. It is helpful to anticipate these changes and view them as new opportunities to educate legislators regarding issues of concern to mental health policy.

District branches' legislative victories and defeats should be shared with the state psychiatric membership through regularly scheduled legislative reports, newsletters, and a Web site and nationally via APA's Psychiatric News and other APA outlets ( 1, 2, 4 ).

It is the responsibility of advocating psychiatrists to engage legislators and policy makers in a constructive dialogue that conveys our message clearly to ensure effective, positive change in legislation and policy making. If we do not get involved and are not willing to put the time and energy into the process to effect this change, someone else will. This may lead to misguided, poor legislation that is detrimental to our patients and profession.

I hope that these guidelines are helpful to state district branch members as they organize to promote legislation and policies within their states to improve the quality of care for patients and to advocate for our profession.

Dr. de Nesnera is assistant professor of psychiatry at Dartmouth Medical School and staff psychiatrist at New Hampshire Hospital. Send correspondence to Dr. de Nesnera at New Hampshire Hospital, 36 Clinton St., Concord, NH 03301 (e-mail: [email protected]). Fred C. Osher, M.D., is editor of this column.