Sunday, February 08, 2015

On Government Oversight and Caring for the Sickest

This is going to be another post on the issue of "Us" versus "Them" because that seems to be what psychiatry is about these days: civil wars. 

First, I'd like send you over to an article in the Wall Street Journal by E. Fuller Torrey and Doris Fuller: Mentally Ill?  Drink a Smoothie.  Torrey and Fuller run the Treatment Advocacy Center-- it's known for for it's vigorous support of legislation that would increase the use of involuntary care for those with severe mental illnesses.  It's one part of their work, and their overall mission is "to eliminate barriers to the timely and effective treatment of severe mental illnesses."  

Torrey and Fuller write a scathing article about SAMHSA --The Substance Abuse and Mental Health Services Agency-- our government's oversight agency.  They point out that of SAMHSA's 570 employees, only one is a psychiatrist who works with the substance abuse side, not the mental health segment.  They point out that the agency's 41,800 word action plan doesn't include a single mention of 'schizophrenia' or 'bipolar disorder.'  Worse, they describes how there is little or no coordination between programs targeting serious mental illness.  The graphic at the top of this post, by the way, is a children's book funded by SAMHSA.  Your mental health tax dollars at work and I'll leave you to decide if that's how you want them spent. 

Torrey and Fuller write:
 The nonpartisan Government Accountability Office this week released a scathing report on the lack of leadership in the Department of Health and Human Services for coordinating federal efforts related to serious mental illness. It described 112 separate programs in eight federal agencies with little coordination. “The absence of high-level coordination,” the GAO concluded, “hinders the federal government’s ability to develop an overarching perspective of its programs supporting and targeting individuals with serious mental illness.” The report was especially critical of the lack of any formal evaluation mechanism for the majority of the programs, so there is no way to tell whether they are working.

They go on to say: 
Meanwhile, problems related to serious mental illness have continued to get worse. Such individuals comprise at least one-third of the homeless population. And according to our analysis of data from the Justice Department, American Correctional Association and the American Jail Association, there are now 10 times more people with serious mental illness in U.S. jails and prisons than in state mental hospitals. Individuals with untreated serious mental illness are responsible for 10% of all homicides in the U.S. and approximately half of all mass killings.
And what has been Samhsa’s response? In September the agency sponsored a “National Wellness Week” during which it suggested that drinking fruit smoothies and line dancing would achieve wellness. And during last month’s “historic” East Coast snowstorm, SAMHSA opened four hotlines for individuals worried about the storm.

Regardless of your feelings about Torrey's work on involuntary treatment, when it comes to issues of how the government is funding and administering care in a timely and effective manner, Torrey is right: the money could be put to better use, we need more effective and timely --and I'll add kind and humane -- treatments for those with mental illness. You'll note that I have omitted the word 'severe.' 

In another article on therapeutic communities, Allen Frances noted, "Advocacy for the mentally ill has been so ineffective in part because it has so split in the often bitter civil war between the medical model and the recovery model."

So this 'civil war' that Frances refers to has been played out in our federal government.  SAMHSA has largely taken on a 'Recovery model' stance, and not a 'medical model' one.  The Recovery movement is, in part, a backlash to conventional psychiatry with opposition to the idea that psychiatric diagnoses convey hopelessness and are dis-empowering, and that psychiatric treatments have been harmful and disrespectful.    The Recovery folks are worried that those who favor the medical model will de-fund (?un-fund) their programs, and they well be right to worry.  There has been a push-back against the Recovery model from people who note that not everyone gets well and that some people do need a more paternalistic doctor-knows-best treatment model focused on medications and illness.  They further feel that the Recovery model conveys blame on those suffering from psychiatric illness -- if only you tried hard enough (and drank smoothies) you, too, would heal.

There's an underlying civil war going on as well, that sort of falls along the lines of Recovery vs. Medical Model but not exactly.  It's the Robin Hood civil war, held by TAC and D.J. Jaffee's, the one says stop worrying about those with mild mental illnesses, the so-called 'worried well,' and move the resources to those with severe mental illness, a very small but very sick percent of people with greater needs.   

I've made the point many times that there is no Us versus Them when it comes to mental illness.  I've run a survey showing that we don't have a clear consensus on who these mentally ill people are (results here)  and in my satire post last week about identifying the mentally ill for purposes of gun ownership, I noted that they don't wear signs on their heads.  Torrey, however, is a schizophrenia researcher and his interest is in patients with chronic psychotic disorders; these people sometimes do wear signs on themselves -- the layers of dirty winter coats they wear in the summer or those who are obviously psychotic who live on the streets and move in and out of jails and hospitals.  Those are the people he cares about.  The suicidally depressed executive who never misses a beat at work,  who goes for therapy and a Prozac script, then has a full recovery within weeks, and quietly goes about living his meaningful life -- he is not Torrey's patient.  

I'm going to contend that Dr. Torrey is right about much of this.  We need more efficient oversight and we psychiatrists involved at the high levels of administration, and we don't need to be funding hotlines for people anxious about snowstorms -- the truly distraught can call the existing suicide hotlines.  We need to include those with severe mental illnesses and to make provisions to help them lead meaningful lives.  

At the same time, I'm going to contend that we can't be Robin Hood, taking from the not-so-sick (those damn worried well who use up society's resources because they can't pull up their own bootstraps)  to give to the sickest.  If a teenager  commits suicide as an impulsive act because he's upset about a break-up with a girlfriend, he's just as dead as a person with chronic, unremitting bipolar disorder who commits suicide.  Someone can be in a crisis that is not mitigated by psychosis or severe mental illness, and that crisis can lead to inability to maintain jobs or marriages or even life itself.  And while half of mass murders --as Torrey tells us - and 10% of all murders are committed by those people with mental illness, then half of all mass murders and 90% of all murders are committed by people without a diagnosis of a serious mental illness.  It's hard to imagine that someone who kills a group of random strangers isn't disturbed in some way, even if they don't fit into the neat little DSM check-off lists.

We need to end the divide between the Recovery and Medical models and have our joint goal be to help people get better -- on their terms and with engagement and respect, whenever possible.  

We need to have timely and effective mental health services available to everyone in distress, whether or not they suffer from psychotic disorders. Clearly, there are people who come for a session or two and the crisis passes, they get something out of it, and they move on without tragic sequelae.  And there are those who need lifetime treatment with expensive medications, help with housing, regular appointments, case managers, daily rehab programs, and a lot of investment.  They should have that, too.  We have plenty of people to spend money on, but what we don't need is more government officials to administer uncoordinated agencies with costly infrastructure that takes money away from providing services to all who need them.  This needs to be our Us against Them: more care/more research vs. less redundant, inefficient beaurocracy.    I'll leave it to you to decide if a smoothie will help.


J said...

Yes, for once I agree with you, Dinah. I am a lifelong sufferer of MDD, severe, recurrent, complete with dozens of medication sequences, years of therapy, 4 life-threatening suicide attempts and several hospitalizations.

I have a PhD and work in a meaningful field. I support myself. I live independently. I have health insurance, I see a psychiatrist in private practice, I have friends and colleagues, many who know about my mental health, many who would be shocked.

I view myself as a patient who falls between the cracks. Prior to finding my current shrink, following a voluntary hospitalization for suicidality, no shrink would agree to work with me because I was "too sick." However, I had a job and health insurance, so I could not qualify for any state or federal run programs. I have never been psychotic, violent, or engaged in criminal behavior. My mental illness is severe and often unremitting. But I couldn't get any treatment and I couldn't get well on my own. Torrey's system would drop me through the cracks. Why is my life worth less then anyone else's, why is my severe mental illness less worth treating then someone else's?

Anonymous said...

This is interesting. Personally, I would like to have the flow of my tax dollars to so called "mental health" completely stopped because I see "mental health", on its various incarnations, a "belief system" on par with religion. Therefore, as far as I am concerned, every dollar the federal government spends in "mental health" is a dollar spent proselytizing a belief system. I find this to be incompatible with the first amendment's establishment clause.

With that said, and given the reality that government needs "mental health" to do social control, I rather have the SAMHSA/recovery types receiving the bulk of the money than the TAC/Torrey/Jaffe people. To make a religious analogy, if we lived in a country where we could not escape the imposition of Christianity as the state religion, I rather have that country promote the beliefs of the Religious Society of Friends (quakers) than the beliefs of the Middle Ages Roman Catholic Church and its Inquisition.

So we will have a "civil war" as long as organized psychiatry continues to promote coercive psychiatry as part of their belief system.

Dinah said...

J : "...I agree with you, Dinah"....words rarely said here on Shrink rap. I'll take it. Glad you found help, and I'm sorry to hear it was so difficult.

Anon: No offense meant to any religion, but the Quakers get their ideology through in more insidious ways. Maybe it's better to have everything out in the open. (--Sorry, years of kids in Quaker school...)

Anonymous said...

It's odd to me that the loudest critics of SAMHSA seem to be completely oblivious to the stupidity that passes for mental health treatment in psychiatric hospitals. You want to see government waste, then sit through some groups in a psych hospital. During one group I was given a list of affirmations to read to a shatterproof mirror. I'm not kidding. This was part of my "treatment."

So, they have these social workers who in some cases got their degree from a cracker jack box leading groups that are worthless, yet if you resist the stupidity it's a sign of your illness. I wouldn't participate in the groups telling me to read affirmations to my mirror so I was labeled non-compliant with treatment. Being non compliant with stupidity is not a sign of mental illness, it's a sign that the patient hasn't given up and has enough fight in them to resist that which isn't helpful.

You want reform? Start with the psych hospitals. Stop with the stupid groups that no one is getting anything out of. You can save some money that way. Instead, encourage social activities which are actually helpful like playing cards, etc.

Given the choice of drinking a smoothie or sitting through a stupid group where a social worker tells me that to get better I need to be compliant with reading affirmations to a mirror, well, let's just say I'll take the smoothie.

P-K, proudly non-compliant with "group"

L said...

I think you should write a post about how best practice does not equal standard of care....but should.

Borderline said...

I agree with Dinah as well. What I was thinking was that by not offering treatment to the "worried well" that might actually result in more severe cases. People could deteriorate more rapidly. I don't have a problem with people who work full time, and want to continue supporting themselves, using their health insurance to maintain their mental health.

Valerie said...

Very interesting perspective! Mental illness is certainly a condition that people should seek professional help on, and the government should be willing to assist those who need it. Of course, the assistance should be monitored so no one abuses it, but everyone who needs assistance should get it.