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Saturday, December 22, 2012

Mental Health System Is Unhealthy

In the past week, we have been bombarded with articles and opinions about the fact that we must, in light of the Sandy Hook School shootings and similar massacres, pay in-depth attention to the Mental Health system in this country.  The point is well-taken. However, it is not well-taken that we can resolve the problem of mass killings with an emphasis on just one or the other of gun control, mental health reform, and the changing of a culture of violence. We must see them working together as necessary elements of an overall plan for cultural change.   

It has come to light that the mother of Adam Lanza had experienced some difficulties with the local school system in terms of the services offered for Adam.  The reports of her disgruntlement or perturbation, and her subsequent moving of Adam to home schooling, seem to imply that it was she who was the problem.  Having gone through a similar situation with a family member (who is listed on the autistic spectrum, but not prone to violence), I am quite sure that Adam’s mother was experiencing the same difficulty that afflicts so many parents of children with a mental disability or challenge: services are often very limited, and too often there are no choices for the kind of help that is warranted, particularly when episodic violent behaviors are involved.  And often, if an appropriate service is discovered, it is not covered by health insurance or any other grant or subsidy.  Such services often can not be accessed by parents because they are simply too expensive.

According to the U.S. Department of Health and Human Services, 20 percent of young people are affected by a mental health problem and nearly two-thirds of them do not get the help they need. Without treatment, these children often find trouble with the law, fall in with the wrong crowd or drop out of school.  We have seen over and over in the last few years, a pattern with the perpetrators of these massacres: they exhibit anger at their circumstances (taking out that anger and pain on innocent victims); social ineptitude, isolation, loneliness, and anti-social behavior often symbolized by their all-black clothing and their lack of meaningful community or individual relationships.

Before we move on to explore this subject, let us make very clear that Adam Lanza’s reported disability is not a disorder associated with violence.  An article dated 12/17/12 by Nancy Chumin for Dallasnews.com explains this distinction and other pertinent facts.
Much has been made of Adam Lanza “as having Asperger Syndrome, a high functioning condition on the autism spectrum which has recently been reclassified as autism. Experts and parents who have children with Asperger’s Syndrome want everyone to know that there is no correlation between autism and violence and express concern that autism is a developmental disorder and NOT a mental illness. Parents of those with autism, who are already too often stigmatized in our society, are worried that this will lead to their kids being further shunned and misunderstood.”

A statement made last Friday by the Autistic Self Advocacy Network supports this: “Recent media reports have suggested that the perpetrator of this violence, Adam Lanza, may have been diagnosed with Asperger’s Syndrome… or with another psychiatric disability. In either event, it is imperative that as we mourn the victims of this horrific tragedy that commentators and the media avoid drawing inappropriate and unfounded links between autism or other disabilities and violence. Americans with autism and individuals with other disabilities are no more likely to commit violent crime than non-disabled people. In fact, people with disabilities of all kinds, including autism, are vastly more likely to be the victims of violent crime than the perpetrators.”

Let us now turn to the story of the mental health system in the last 30-40 years: it is one of deinstitutionalization, the gaining of rights for the mentally ill, the evolvement of community-based services that are still evolving because of drastic cuts in state budgets, and the re-institutionalization of certain people with mental aberrations who ran afoul of the criminal justice system and were incarcerated. 

Based on 25 years of experience with the NYS Office of Mental Retardation and Developmental Disabilities (which started out as part of the NYS Office of Mental Hygiene), I believe that the lack of a full-blown, well-financed plan for de-institutionalization of persons with mental illness, an over-emphasis on certain rights which sometimes mimicked the absurd and often endangered ordinary citizens, plus a community-based service system that was never able to meet expectations or the special needs of those who needed it, meant that something close to chaos ensued.  On the other hand, with less emphasis on rights to live as one wished, and more emphasis on “normalization” to live as closely as possible to what is normal for others, OMRDD was able to establish a community living experience for persons with developmental disabilities by utilizing small residences, community-based programming, and integration into public schools. 

In contrast, the separate Mental Hygiene department was saddled with a movement for rights which ended up with persons living on the streets after de-institutionalism, people not taking their much-needed meds, with few opportunities for programs that met their needs, and with fewer housing choices.  Strict restrictions on initial institutionalization, or re-institutionalization, practically made beggars and antagonists of those caregivers who could not cope with abusive and dangerous behaviors, and who tried to find help, often with no affordable results.  In 1980, landmark legislation -- the Mental Health Systems Act of 1980 -- fostered the continued growth of America’s Community Mental Health Centers which allow individuals with mental illnesses to remain in their home communities with minimal hospitalization.  Subsequent and continuous cuts in funding at the state and federal levels prevented a full-blown community mental health system from being fully realized.

Not only did the Mental Hygiene system have to deal with a radical set of freedoms that sometimes ignored the rights, safety and protection of the general public, it stumbled in terms of the volume and adequacy of community services able to be funded and made available to those who had been de-institutionalized.  In many states, it did not help that de-institutionalization offered an opportunity to cut state budgets.  Those cuts became draconian in some areas, and added to the already inadequate community-based mental health services. 

Along came new generations of applicants for services, and the system was strained to the breaking point.  In my humble opinion, it has never recovered, not only because of the factors I have mentioned, but because in our culture, mental health has never been well-understood, nor accepted as important enough to spend the money needed to enhance it, nor accepted on a par with physical health.  And unfortunately, our culture has long demonized mental illness, looked at it as dark and evil ( Dr. Jekyll and Mr. Hyde) and cast some who portrayed symptoms as monsters or as animalistic (Pyscho, Silence of the Lambs;  Jeffrey Dahmer, many others).   We tend to fear the unknown, and we can only blame ourselves for the on-going ignorance and mythical approaches to the subject of mental illness that endure in our culture. 

All of which leads us back to current events, and the need for a plan to look after people who begin to exhibit violent or aversive behaviors and attitudes at young ages.  Adam Lanza is just one more example of the lack of, the unavailability of, and the inadequacy of mental health services. 

It is indicative of where we stand, and of what we need.  We are told by ehow.com that one in five American adults will experience mental illness at some point in their lives. However, only 40 percent of them get treatment. People do not get treatment for mental  disorders for many reasons but difficulty paying for treatment is one factor.  So perhaps that is where we need to begin to change the system:

1) The Affordable Care Act must be amended to require all health insurance carriers to cover all aspects of mental health treatment without imposition of limitations or caps on the number of days they will cover in-patient mental health care or on the number of outpatient visits to counselors or psychiatrists; parity of mental health benefits with other health coverage is imperative
2)  Early intervention and preventative measures are also imperative.  We cannot make substantial progress in mental health reform without this, and trained clinicians are key to making early diagnoses as well as appropriate referrals to proper services. 
3) We need an integrated health delivery system that attends to both physical and mental ills and behaviors, and which follows children with symptoms in an on-going manner, particularly those who get mixed up with the juvenile justice system.  Identifying and integrating mental health needs into traditional health care, social services, community, and work-site settings is particularly important for youth and those who have experienced trauma;
4) We need many more community health centers that are staffed with doctors and nurses trained in both physical and mental health and healing; access to such a system must be made to be as open and easy as possible;
5) We need a data system that tracks the healthy and unhealthy symptoms of patients, along with treatments that work and don’t work; that system must be applicable across all jurisdictions
6) We must educate our adults and our young in the realities of mental illnesses
7) We have to develop new protocols for reporting episodes of violence to an authority that is equipped to act, to counsel, to protect others, to coordinate a plan for services.
8) We must have residential centers, other than institutions or jails or emergency rooms, that can fill a need for short-term, emergency in-house care, and respite care, as well as longer-term stays.  The Affordable Care Act, (Sec. 2703 & Sec. 19459(e)) already calls for States to build person-centered health homes that can result in improved outcomes for beneficiaries and better services and value for State Medicaid and other programs, including mental health and substance abuse agencies, but funding is still key, and on the federal level, Medicaid is under attack.
9) We must acknowledge, and build upon, the many advances already made in the Mental Health field, and must enlist mental health organizations -- that have already influenced and brought about many positive changes through a combination of public education and support for ground-breaking legislation -- into a broad coalition of such organizations to  further the cause of reform
10) We have to encourage more research into the causes of violence in individuals; this cannot be overlooked, since we also need to find ways to treat particular types of violent disorders, but we must also take great pains to deal with a common misconception that all people with mental illness are violent or dangerous. 

“In 2005, a Canadian journal published a review of all relevant past research on risk assessment for violence among people with mental illness. One dominating theme of the review was that violence can be much more accurately predicted by attending to non-mental health variables compared to mental health factors. These variables include age, gender, socioeconomic status, education, and environment. Additionally, a history of violence is a much stronger predictor of future violence than any mental health-related variables. 
“Researchers point out that, more than substance use disorders alone or mental illness (particularly psychosis) alone, it is the co-occurrence of the two disorder types that seems to escalate the risk for violence. In fact, having multiple diagnoses of any kind increases violence risk factors. People with co-existing diagnoses, depending on the number of conditions they have, are up to six times more likely to commit a violent act in the past year than people with one type of disorder. The reason behind this link is not yet fully understood.
“Furthermore, current studies indicate that alcohol and substance abuse far outweigh mental illness in contributing to violence in society. For example, citizens are much more likely to be assaulted by someone suffering from an addiction than a major mental disorder such as schizophrenia, notes the review. The report concludes that it is unlikely that a member of the public would be at risk of violence from a person with a mental disorder who does not also have a substance use problem.” (article on Mental Disorders at HeretoHelp.com)  All this speaks to the fact that in-depth research is needed to clarify the causes of violence.

These have been merely a few suggested steps to be taken toward reversing the trends toward isolation, segregation, and inattention to the need for adequate mental health care.  The list is less than adequate and many more in-depth suggestions are needed; the SAMHSA site provides a possibility for submitting such ideas: http://www.samhsa.gov/healthreform
 
In fact, complete resolution is impossible, no matter what we do, but in memory of children, young people, and adults killed in civilian massacres, we cannot fail to do something, and that something must be in the form, insofar as possible, of a common-sense broad-based plan including gun control and mental health reform that seeks to change a culture that makes an idolatry of violence, of rugged individualism, of social Darwinism (that only the strong shall inherit the earth), and that demonizes mental illness.  A strengthened Mental Health system is crucial to a society that wants to deal wisely with troubled individuals who may be prone to violence.  It is one of the legs of a structure upon which we must stand to lend support for our basic concepts of life, liberty and the pursuit of happiness.   A culture of violence is antithetical to the survival of such democratic ideals. 

A December 14th article on AlterNet by Lynn Parramore sums up the situation politically:

“Inadequate gun control is only one half of the story. The other is the shameful job America does of treating the mentally ill. Today, 45 million American adults suffer from mental illness. Eleven million of those cases are considered serious. Most of these people are not dangerous, but if they can’t get treatment, the odds of potential violence increase.
Yet the mentally ill are finding it increasingly difficult to get help. Mental health funding has been plummeting for decades. Since 2009, states have cut billions for mental health from their budgets. As Daniel Lippman has reported in the Huffington Post:
‘Across the country, states facing severe financial shortfalls have cut at least $4.35 billion in public mental health spending from 2009 to 2012, according to the National Association of State Mental Health Program Directors (NASMHPD). It's the largest reduction in funding since de-institutionalization in the 1960s and '70s.’
“Thanks to the misguided austerity policies embraced by conservatives, more people are falling through the cracks. There are not enough psychiatric beds, treatment services or community support programs. Medication is expensive, and insurance companies routinely leave patients inadequately covered.  Mental healthcare workers have been laid off. Vulnerable people are neglected until their situation becomes acute – often after it’s too late. Many are incarcerated, often subjected to solitary confinement because prison officials don’t know what to do with them. Others are homeless – as many as 45 percent of the people living on the streets suffer from mental illness.
“This situation is no accident, and it is not inevitable. Economics 101 tells you that when you have a massive economic crisis, the government must step in to fill the gap until the economy can recover… The U.S…. is well-equipped to provide stimulus money to states to make up for budget shortfalls. What gets in the way of meaningful action is political obstruction, not economics. Federal stimulus dollars and other grants have made up for some of the cuts to mental healthcare, but thanks to constant efforts [of the Right-wing] to block adequate stimulus measures, not enough. And if conservatives have their way, budget cuts to programs like Medicaid will continue to ensure that high-risk people can’t get help.
“The [Radical] Right’s program for public safety appears to be that everyone should have a gun and few should get adequate healthcare. That’s a recipe for death and destruction. Killing sprees are on the rise. How many more people will have to die before mental healthcare becomes a national priority?”   (Lynn Parramore is an AlterNet senior editor)