Today, I have seen several news stories about cuts in mental health. On CBS news, there is a slide show with the top 15 states that have cut services from 2009 to 2012. The states range from Missouri and Idaho to Virginia, Massachusetts and Washington D.C. (I know, it’s not a state but it’s listed).
Then, I saw that our local mental health hospital, Lakeshore Mental Health Institute will shut down in June of 2012. One of the reasons? Patients do better in the community. Sure they do.
Finally, I saw that no psychologists or psychiatrists want to take Tricare, the insurance for military personnel and many soldiers and their families are having trouble getting services:
TRICARE’s psychological health benefit is “hindered by fragmented rules and policies, inadequate oversight and insufficient reimbursement,” the Defense Department’s mental health task force said last month after reviewing the military’s psychological care system.
Just wait until Obamacare kicks in, then no one will be able to get services. But at least people will feel good about themselves. I also want to point out that many times, people think that it was the Republicans closing the mental hospitals and putting people onto the streets. Nope, that trend started with Jack Kennedy:
Numerous social forces have led to a move for deinstitutionalisation. However, researchers generally speak of six main factors: criticisms of public mental hospitals, incorporation of mind-altering drugs in treatment, support from President Kennedy for federal policy changes in the treatment for those with mental illnesses, shifts to community based care, changes in public opinion of those with mental disabilities, and individual state’s desire to reduce cost of mental hospitals.[1]
Now, many of those people who were in hospitals are in our jails and prisons. Is that an improvement?
Nicholas Cummings in the book Destructive Trends in Mental Health: The Well Intentioned Path to Harm discusses the problems that mental health professionals have had over the years. One is that they are too political and because of that (in my opinion), there is no respect for my field any longer. It could be that the public sees us as a bunch of quacks. However, throwing the baby out with the bathwater isn’t the answer. There are many people out there who are hurting and many of them do get help. Indeed, in my career, I saw people in mental institutes who saw the place as their home and did not want to leave.
Anyway, I guess when times are tough, mental health is the first to go. What do you think? Is this good, bad or are you neutral on this trend?
Dr. Helen,
You are so right. I have been in Law Enforcement for 36 years and I have seen many of these changes first hand. More and more of our dangerous situations involve the mentally ill (at my agency, our last 2 barricaded suspects had long mental health histories). We are exchanging one form of involuntary commitment (mental health facility) exchanged for another (jail). We in Law Enforcement are put in a no win position. The mentally ill who can’t stay on their meds or treatment commit crimes and get arrested but the last place they should be is jail; but sometimes that is the only place we can put them where the continue their treatment under supervision. Some mentally just cannot function outside a controlled setting.
Additionally, if Lakeshore does close and Penninsula has no beds, Sheriffs will be transporting the mentally ill to Chattanooga and Nashville. A bad situation is getting worse.
Sadly, my first thought when I heard about the planned closure of Lakeshore was “Wonder who has a project they want to put on the property.”
Hospitalization peaked, in 1955, and began to decline with the widespread availability of Thorazine. It was the exclusion of Institutions for Mental Disease (i.e state mental hospitals) from coverage under Medicare, in 1965, that really jump-started the process as states sought ways to transfer the costs of treatment to the Federal government.
Now, many of those people who were in hospitals are in our jails and prisons. Is that an improvement?
Yes. Jail sentences are limited, and there is only so much that can be done to you in jail. Involuntary incarceration in a mental hospital used to be indefinite and there were pretty much no limits and no recourse for the “patients”. They were completely dependent on the goodwill of the staff; if the staff chose to abuse them, there was no legal way to resist. If I were given the choice of a specific jail sentence or indefinite commitment to a mental facility, I know which I’d be safer in, and which I’d have a better chance of getting out of.
Notice how all the ones who say it’s bad gloss over or outright ignore all the issues with the mental health system. ESPECIALLY prior to the 60s. The extremely poor or no-existent treatment, housing conditions that make some of the worst prisons look like 5 star hotels, the works. But we won’t talk about those times because then we can’t make the case the mentally ill are truly worse off.
Is what we have better? In some ways yes. Anyone here volunteering to be locked up for the rest of their life on the say so of a doctor with no means of recourse? How about being force-fed untested drugs multiple times a day without any way to say no? Anyone?
In other ways they are no worse off than prior to the 60s. They’re not getting the care they need, health care professionals by and large do not treat the mentally ill as human beings in need of care, and a host of pharmaceutics being used where not only do we not know how they work, but we have no idea of the long terms effects of these drugs are.
If were going to stick with the binary “Are they better of now than before”, then I have to say yes, they are. If we allow more complete answers to the question they I would say that while they are better off than they were as little as 40 years ago, we still have a long way to bring care up to the standards we have for prisoners.
Now, many of those people who were in hospitals are in our jails and prisons. Is that an improvement?
think that would depend on the ratio of those “that do better in the community” to those that are incarcerated; is there any such data available?
The last time they talked mental health cuts(which they never did) we got the
mentally ill on the streets and homeless. They the Leftist reformers are always
good at expanding the social services industry. More people work in the homeless
industry than there are actually homeless. Also true of people working in HIV/Aids field. Social services budgets never decrease.
Dr. Smith,
I’ve seen both the good and the bad of the traditional mental health care system. My uncle has suffered from paranoid schizophrenia for the last 45 years. His health care is paid for through VA. But even back in the 60s, when both the VA and the mental health system were supposedly better than today, my parents had to get help from their senator to poke the VA into paying benefits.
For years, my uncle was in a VA hospital in northeastern Ohio. It was the kind of cold, sterile place depicted in the movies. Even though they knew damn well someone with his severe illness does not improve, the docs gave up on him. My grandparents were concerned but didn’t know what to do about it. My mom had a hissy and served notice to the staff that my uncle was not to be “housed,” and to continue efforts to help him function closer to normal. That worked for a while–so well, in fact, he was actually able to leave the hospital. But as you know, those victories are short lived.
That VA hospital closed years ago. Today he is in a small residential-type program in southern Ohio. My mom says it’s more like a home, where residents are treated like a big (dysfunctional) family rather than a group of sick people. He is no longer left alone to slide into catatonia, and he hasn’t had a shock treatment since leaving the VA hospital. So while he’ll never be able to live on his own, he at least is living as full a life as he’s capable of.
Just from my family’s experience, I think the smaller programs are better than the big warehouses of the past. It makes sense, not just from a psychiatric standpoint, but from an anthropological one–smaller communities can be much better at providing individualized support.
We can have a mental health system that’s the envy of the world–IF we get rid of ObamaCare and reform health insurance so it is sold in a truly free market. The reduction in costs would expand the market so that every community could, ideally, have a place for their most fragile members to get help.
Bad. There are a stack of serious problems caused by deinstitutionalization–which has roots even earlier than Jack Kennedy. We are spending money on prisons for mentally ill people because the alternative was treatment before they killed someone. We are spending money on homeless shelters that, in some cases, use what use to be public mental hospitals (such as Creedmoor in New York). We are spending more than $50 billion a year on treatment for schizophrenics, and more than $8 billion a year in disability payments–and there is reason to think that early treatment would at least reduce severity for some.
My agent is hunting for a publisher for my next book, My Brother Ron: A Personal and Social History of the Deinstitutionalization of the Mentally Ill. You can read the first several chapters here.
People suffering from mental illness are mostly dependent on public health systems. Many public mental health systems are run poorly, but in general cutbacks in those systems typically displace costs. They don’t reduce them. In fact, in most places total social costs will be higher with lower public mental health expenditures, but those costs don’t show up directly as line items in state, county or municipal budgets. Unreimbursed medical costs, public safety expenditures, costs of increased crime and incarcerations all rise.
De-institutionalization created winners and losers. Systems were horrible. Winners include people who didn’t need to be institutionalized and those who won’t face that now. Losers include those who simply can’t live independently, show up for appointments, take their meds, etc. They live “free” but much of that is an illusion. Throw substance abuse into the mix, and you have today’s long-term homeless population. Are they better off? We can’t use many of our parks and public spaces. Are we better off? Better to re-engineer our support for mental illness and substance abuse, focusing on the best, least-cost set of institutions and services to address the myriad of problems — being honest about ALL the costs in the process.
Some communities have been proactive in dealing with this. Supportive housing is a combination of affordable housing and social services for people with mental illnesses, drug/alcohol abuse, or both. Ann Arbor, Michigan has an organization called Avalon Housing which provides this. The clients live in Avalon-owned/managed apartments in the center of town, near all the social service providers and public transportation. The apartments are mostly in renovated older homes, and they are gorgeous–the envy of the college students and professors in this chic college town. There’s also a development of townhomes built especially by Avalon for families. The townhomes are also well-built and beautiful.
The results of supportive housing in Ann Arbor are pretty impressive. The majority of clients have lived in an Avalon home continuously for 5 years or more. Most have been able to stick to their treatment regimens and keep a job. A big reason for the success is that the residents have “skin in the game”–they sign a lease, pay rent from their own pockets, and manage their own finances. They live completely independently but are expected to utilize the services to help them live productively.
This kind of program requires the community to work together, rather than waiting for Nanny Sam to do it. Avalon Housing is the kind of community-based mental health program I’d love to see in every city. We can make it happen IF we have the will. Getting rid of ObamaCare would be a great first step.
I’d blame Sylvia Plath- you know, the glamorized, elegant, I’m so bitter about everything, but not really ill. the suicide was a tantrum sort of thing. Or, that notion that mental illness is just a bad character phase, a wan-ness in the face of responsibility.
It’s really hard to explain what it looks like, day to day, to someone who hasn’t seen it up close. It’s easy to see a broken leg, or a missing arm.
OTOH, we did just have a generation completely jacked up on drugs, and rebellious of everything normal. It would be crazy expensive to treat the baby boom’s self- inflicted mental damage, and it would have been horrible for their parents to institutionalize them all. Good stuff happened, too, and it never looked good at first. The assumptions I make about the world today, did get me grounded on a regular basis- little things, like a black guy could carry my books home, or that I could call a boy for the homework pages. I’d hate to be set with the 1950′s generation having police power over everything.
As an RN it is my opinion that once we actually decide to treat mental illness as a disease in which patients have to participate in their road to wellness as much as someone who is diabetic must or the patient with cardiac disease needs to change their lifestyle then and only then will mental illnesses be considered on par with physical illnesses.
I am speaking primarily of the typical patient seen repeatedly in an inpatient setting with multiple complaints which never seem to go away but instead simply shift. For some reason it is always the responsibility of the health care person or system to take care of these patients, but it is never their responsibility to follow a treatment plan. The drug seeking patient is much the same. Recently the CDC came out with a study regarding patients who are addicted to pain medications, and there is a wonder what the problem quality to it. Any nurse in health care can tell the powers that be what the problem is. Joint Commission mandates that we treat pain as the patient says they need, not by what we observe. The patient who comes in with 10/10 chest pain while joking with friends, requesting something to eat while watching AND enjoying TV is not likely a true 10/10 pain, yet it is the rare physician who will refuse IV narcotics because everyone is afraid to of the repercussions of
doing so.
The issue to a large extent is that what qualifies as a mental illness has been expanded to include anyone who simply refuses to grow up and behave like an adult. So the ability to discern who truly needs treatment vs. those who suck up services-the drug using freewheeling, I don’t have to provide a damn thing for myself so you must support me-has been taken away and thus money that should go to people who truly need help has been vacuumed up by those who will willingly vacuum up everything and still whine no one will help them.
We as a society also have to come to terms that some people are impaired enough and will not get better, that they must have some viable method of being taken care of.
Not all pain can be made to go away, we simply have to have a method to make it bearable. Some mental illnesses are not going to get better and for the sake of the patient as well as society there has to be a viable, humane method of taking care of those patients. This requires mental health professionals to be advocates for something more than left wing ideology however plus it requires the exorcising of the demons of the past in mental health, including its whole hearted embrace of eugenics in the early 20th century. But perhaps more than anything it means truly treating mental illness like any other disease. If a person is diabetic and requires insulin they get insulin and are taught how to use it, a person who has a mental illness is poorly encouraged to understand the part behavior modification or lifestyle changes has in their ability to get better. I am not speaking of schizophrenia, which we understand so poorly, I am speaking more of the bipolar patient or those with personality disorders. While treatment is a large component of their ability to be healthier it should be a given that they must use behavior modifications in the same way a diabetic or heart disease patient must, in order to control their disease process.
Some things cannot be cured, they can only be controlled.
One is that they are too political and because of that (in my opinion), there is no respect for my field any longer.
Well, anyone who has watched the circus of DSM revisions can’t help but come to the conclusion that those at the top are too political. Getting down to practitioners at your level … I don’t know:
It could be that the public sees us as a bunch of quacks.
Could be. Too many of your genuine cures depend on on “people taking their meds” and many of them are fairly nasty, e.g. the atypical anti-psychotics (I had to take one for a little while after my doctor screwed up and prescribed a drug which made me hypomanic, something he didn’t really notice until my GP told him when they met in the cafeteria…). And I gather it’s hard for many with bi-polar disorder to consistently take their meds.
Combine that with the “wild in the streets” (a book title from a few decades ago) deinstitutionalization problems we’re discussing here and it’s hard to make the case that the mental health profession has its act together. Hmmm, perhaps if more of the profession’s political efforts were put into addressing this general issue you’d get more respect.
I’m not saying you’d be successful, since these institutions are poor ways of buying votes, but if you overall didn’t give the politicians political cover in shutting them down….
Then we have present days abuses like the VA’s excessive reporting of vets to the NICS system, depriving them of some of their 2nd Amendment rights without a proper adjudication (PTSD in the Clinton days, having someone else manage their money today) … if any mental help professionals are denouncing this they aren’t get much exposure, even in the gun blogs and the like.
Funny thing–we were discussing this very subject at a county-level meeting on MH/MR funding. (Forgive me for not using the euphemism-du-jour–I can never keep up with the fashion trends.)
Here’s the deal: everybody, everywhere, is talking about “entitlement reform.” It will happen. But AARP has a big, shiny office building in Washington that is chock full of lobbyists who will fight to the death (or at least the end of their expense accounts) to make sure that entitlements for the elderly will go untouched.
The politicians will be bold; they will be brave; they will “go big.” They will ruthlessly cut funding for mental health, mental retardation, special education, learning supports, and long-term care for the mentally disabled.
The states aren’t waiting for the feds: Pennsylvania has “reformed” their mental health system, by removing (reportedly) 100,000 with mental disabilities from Medicaid assistance since July 1. The county MH/MR coordinatrix repeated a rumor that in the 2012-2013 fiscal year, Early Intervention will no longer be an entitlement for the mentally-retarded.
I’m sure this thrills the libertarians no end–or it will, until the MH/MR population end up on steam vents in Manhattan. (Well, the men will: the women get raped, murdered, and their bodies dumped in the East River when the tide is going out. But nobody wants to talk about that.)
Social conservatives want to judge a society by how it treats its most vulnerable members. But both social conservatives and libertarians are adamant that entire federal agencies must disappear. Who is the voice on the right who speaks for the institutionalized? Those who, literally, cannot speak for themselves?
I’m trying. The deinstitutionalization movement was never primarily (or even secondarily) about saving money. It was built on fine sounding ideas that had little to do with the real world. But repairing our mental health system, while it won’t be free, isn’t as expensive as everyone assumes, because the costs of our alternative system are shockingly high.
By the time many of the criminal mentally ill finally do something serious enough to get attention, it is not public urination, or sleeping overnight in a park, it’s rape, or murder. Locking people up for five or fifteen years–especially those who are mentally ill–is very expensive. Mentally ill prisoners are nearly twice as expensive to keep in prison as mentally healthy prisoners. It isn’t good for either the mentally ill prisoners, or the prisoners who share facilities with them.
Homeless shelters aren’t free, either, nor is the cost of cleaning up messes caused by mentally ill people using public libraries as dayshelters. A friend who worked as a librarian in Santa Rosa told me that they spent a lot of money cleaning the carpets of urine, because so many of the mentally ill homeless did not bother using the bathrooms.
Criminals should be put in jail.
Others should not be incarcerated against their will.
The idea that a third party should be able to pronounce one insane and the power of the state used to strip him of all rights, dependent wholly on the good graces of the state and that third party, is abhorrent to all freedom-loving individuals.
I’m sure there’s no need to recount the historical abuses to make that point.
Spoken like someone who’s never actually known anyone who is mentally ill. “Freedom” for someone in the grip of schizophrenia can be truly hellish. A schizophrenic I knew very well was totally convinced that everyone she knew and loved was conspiring against you. She knew this because (i) she saw their knowing looks at each other, and (ii) the voice of God told her so. She was desperately afraid of everyone and everything. She couldn’t trust anyone, and she couldn’t even trust her own senses.
Now how do you help someone like that without coercion? When her medications are working she acknowleges that she needs them, but when they’re not working or absent she is adamant that she doesn’t want or need them. The side effects are unpleasant, and the voice of God tells her that there’s nothing wrong with her, that the doctors and her loved ones are all conspiring against her.
You think she should just be free to suffer horribly. Never mind that she is unable to think clearly enough to make rational decisions. To you, it doesn’t matter how bad her decisions are, or how many times she is raped or beaten out on the streets. No, all that matters is your notion of “freedom”. What you are forgetting is that freedom presupposes that you are rational enough to be able to be responsible for yourself. That just isn’t true of some mentally ill people.
Once you admit that some people are too ill to be allowed to make their own decisions, you’re stuck. Someone has to be able to make these decisions.
Yes, there have been abuses, and there probably will be some in the future. But that only means that we need to monitor those we pay to care for the mentally ill to be sure they are doing a decent job. Just as we need to monitor prison guards, policemen, judges, teachers, politicians and everyone else on the public payroll. That doesn’t mean we don’t need any of them.
We swapped one set of abuses (usually neglect, in large publicly operated institutions that at least could be supervised) with another set of abuses (almost always neglect, in alleys and places that are hard to keep on eye on). Mental illness is a hard problem. Pretending that letting them freeze to death or die of pneumonia is more humane or liberating is delusion.