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Our Failed Mental Health System

Jill

This article in the New York Times Magazine is a must-read. It looks at the many ways our system is failing the mentally ill and their families — how there are few good options, and mentally ill people end up being cruelly cycled through emergency rooms and jails while their families hit wall after wall in trying to get help. I wish the author would have focused a bit more on the civil liberties issues — there are bars to involuntary commitment for good reasons — but the current set-up isn’t doing much good.

33 thoughts on Our Failed Mental Health System

  1. This really hits home for me. My brother developed psychosis earlier this year after repeated use of of hallucinogenics. I live a long ways aways from him but immediately knew something was wrong when he called me in the middle of the day at work and alternated between laughing hysterically, ranting, crying, and talking about killing himself.

    I was understandably terrified and was able to contact someone to watch him. I thought he was tripping and would be fine the next day. Well the next day rolled around and he hadn’t slept all night and was still speaking incoherently. I had the person with him take him to the emergency room where the doctors tried (and failed) to sedate him and then released him, saying that he just needed to come off the high. I had him readmitted THREE times and only got a psych evaluation to happen when I called a former boss of mine who was the head of a crisis center and got her to pull strings for me so that he could be committed.

    Even then, I had to hope that he would talk about self-injury or harm to others because that was the only way they would admit him to the psych facility since he didn’t have insurance.

    Our mental health services system in the country is a mess and it will remain so as long as we keep underfunding services. Income should not determine a persons access to mental health. Right now most states only step in to help once someone is dead, trying to become dead, or utterly unable to care for themselves any more. This makes it almost impossible for a mentally ill person to really recover and it takes a huge toll on family and friends who are trying to provide support.

  2. The police had been to the house a couple of times, but there was not much they could do. In order for them to take him to PESS, or for the psychiatric screeners at PESS to commit him involuntarily, he had to be an imminent danger to himself or others. Domestic violence and verbal threats met that standard, in theory. But in practice, it seemed to mean that he had to be standing on the ledge of a building, or holding a knife to someone’s throat at the very moment the police arrived.

    Ok, so I know this comment is probably going to earns some boos from my fellow commentariat but: despite my deepest sympathies for this family (and empathy- I grew up with a bipolar parent), there are really, really good reasons for this. Especially considering the ways that involuntary commitment and psychiatry in general have been used against marginalized community (diagnoses of Oppositional Defiant Disorder have been used as a weapon against POC for decades) I am pretty comfortable with incredibly stringent requirements for committal.

    There are tons of things we can do to improve access to mental health services- more funding, better training at ERs and hospitals, more early prevention and education- but involuntary commitment should always be really hard to do. This sucks for families who need it- like the one in this article- but I don’t think there’s a better tradeoff.

  3. I wish it was easier to get into care earlier, before people slip down to an extreme level. As the author mentioned: getting a psychiatrist is incredibly hard, and without a psychiatrist you cannot get medicine.

    Imagine a person with diabetes or a bad heart condition being told that they have to wait 2 months or more for life saving medicine or that everywhere they turn is too busy to accept them. That they need to admit themselves to the psych ER (further clogging the system) in order to be seen by a doctor. Insurance companies don’t take mental health seriously enough to provide adequate coverage, so mental healthcare- even to those with insurance- is a luxury.

    I, for example, had to drop out of therapy as a child because it was to expensive. My younger sister wasn’t able to go, even though I begged my parents numerous times (she was tortured and violent at times) because they couldn’t afford it. My relatives and I go off meds sometimes in order to stretch out the prescription and save money.

    Now, as an adult I have been to the ER 3 times in order to refill my medicine because I couldn’t find a psychiatrist who would see me. I’m currently debating whether to leave my current therapy because (even with insurance and haggling down the price) it’s a big burden. As for psyciatry, I’ve been trying for months to get a doctor who can see me and is not expensive- to no avail. And all of this fucks up my condition and sends me closer to throwing my hands up and commiting myself to a hospital or worse.

  4. …involuntary commitment should always be really hard to do.

    i agree with amblingalong. i’m only halfway through the article (reading about mental health issues can be triggering b/c of my own experiences so i’m reading it in small doses), but so far i’m not very happy with the amount of focus there seems to be on almost equating mental instability with violent behavior, neglecting to talk about the violence and crimes committed against folks who are in mental distress or who are non-neurotypical. and maybe i missed it, but so far i don’t think the article has quoted an actual mental health consumer/survivor/patient who has been through the committal process, only family members and clinicians. i’ll keep reading…

  5. I’ve also been on both sides- having to go through it and being terrified of getting put in against my will (it’s one of my worst nightmares) and hoping to God that someone I care for who is slipping will “hit rock bottom” and qualify for forced hospital stay.

    It’s a shitty situation, but there’s really not much you can do. It’s the same with normal ER laws- if someone refuses treatment, and they aren’t unconscious or their illness isn’t a threat to others, there’s not much you can do.

    1. Agreed that involuntary commitment should be extremely difficult. What’s troubling, though, is how the definition of “a threat to themselves or others” has shifted mostly because of lack of resources. Someone can be a very clear threat to themselves or others and still not get the help they need — or only get it once they’ve done something dangerous and are incarcerated or in the ER, and are then put back out on the street without necessary support.

  6. What’s troubling, though, is how the definition of “a threat to themselves or others” has shifted mostly because of lack of resources. Someone can be a very clear threat to themselves or others and still not get the help they need — or only get it once they’ve done something dangerous and are incarcerated or in the ER, and are then put back out on the street without necessary support.

    /cosign

  8. Jill, I’ll say that the view from the inside is that the shift in definition of “immanent threat of harm to self or others” has had as much to do with more respect for civil liberties amongst providers as it has had to do with money. Thats not to say that money isn’t a big part of the problem (especially when it comes to ERs) but one of the reasons its become harder to involuntarily commit people is because of people like me. I’ve been on the other side of the table from the author, I’ve had family members walk out disgusted that I wasn’t on their side, I’ve pissed off bosses by not only refusing to sign paperwork but calling ER doctors to tank a commitment I thought was bad. I’m sure that in more than a few people’s personal stories I’m the villain.

    I’m OK with that, though, because most people don’t have any real idea of what an involuntary commitment means. It means a complete loss of civil rights, a loss is at least partially permanent in most cases. It means going to a psych facility where abuse or neglect might well be the norm rather than the exception and going under circumstances that all but guarantee that no one will believe you even if there are marks. Going to a psych facility, in some cases, means medication against one’s will. No, you can’t force someone to take their meds, but you can definitely give them a “safety related” PRN. People lose their jobs, they lose their freedom, they lose their rights, they lose their dignity. I’ve had more than one patient who would prefer prison over a state psychiatric hospital, and there are some short term facilities in Chicago that I’d definitely take a stay in county over.

    Reading the article I heard a lot of things that struck me as off. The constant invocation of rare cases of violence, laws named after dead people, an embattled family member telling a story about how hard their life has been as they send their sick relative to jail because they don’t know what else to do. Tough situation, I’m sure, but you can tell a lot about the argument’s aims. She isn’t looking for better funding or better training or more access to treatment, the lack of those things are invoked as evidence, but the remedy that is offered again and again is the power to force mad folks to do what their family knows is best for them. I’ve had a lot of patients broken on that wheel, and I spent my time on it as well. Color me unimpressed.

  9. ok, finished the article, and like William i am unimpressed. i’m glad that there are families and loved ones who recognize that the mental health system is broken, but honestly, i’m tired of reading articles like this that are so focused on the pain and anguish of the loved ones and don’t bother to give much of a voice to the people who are actually going through the experience of hospitalization, imprisonment, and treatment. I was honestly expecting the article to end with news of the father’s death, because his voice is so utterly lacking from the piece, and that’s really sad.

  10. i’m tired of reading articles like this that are so focused on the pain and anguish of the loved ones and don’t bother to give much of a voice to the people who are actually going through the experience of hospitalization, imprisonment, and treatment.

    Its almost like you think that psychological services ought to be focused on patients and their needs rather than the anger and anguish of family members saddled with such a terrible burden as a mad relative.

  11. Its almost like you think that psychological services ought to be focused on patients and their needs rather than the anger and anguish of family members saddled with such a terrible burden as a mad relative.

    Focused, yeah, but I’m not going to pretend that being crazy isn’t a burden for everyone in my vicinity either.

  12. I worked as a mental health case manager, and I have no idea what to fucking do about chronically seriously mentally ill people. Largely because they can’t be helped. To allow them the greatest freedom often means they live in squalor and danger, to confine them usually results in even more serious pathology (not to mention vulnerability to abuse). There are not enough people in this world who can handle the stress of dealing 40 hours a week with mentally ill people, let alone do it for pennies, do it for 60, 70, 100 hours a week. I fully admit I cracked under the pressure and ran. I will probably never return to the field–I still have nightmares and panic attacks about the living Hell that my old job was.

    I knew a woman that regularly urinated on her couch and kept her insulin in neat stacks on the counter, never to use it or refrigerate it. She’d have what I thought were minor seizures where’d she stare blankly into space, her head dipping, a lit cigarette in her hand. She set herself on fire repeatedly. We finally concluded we could institutionalize her once something rotted off her living body.

  13. There are not enough people in this world who can handle the stress of dealing 40 hours a week with mentally ill people

    I’m not so certain thats necessarily true. I’ve worked in the same role and it was hellish but I’m not so certain that the patients made it so. If the money was better, the caseloads were smaller, and the system was designed to actually help with (with the resources necessary for that) rather than to look busy and avoid liability I don’t think the the outcomes for the patients would be so traumatizing for providers.

    One of the big problems, as I’m sure you remember, is Medicare/aid. A lot of patients have trouble finding psychiatrists because a lot of psychiatrists don’t want to put up with the billing requirements and below-market rates paid out…eventually. Medicaid just flat doesn’t pay for individual therapy and what Medicare pays is a joke. The same problem exists for hospitalization; chronic mentally ill patients tend to be very poor, which means they get medicaid or medicare, which means that the hospitals available to them aren’t going to have the highest standards of care. Nursing homes, the closest thing we have to assisted living for mad patients in Illinois, are savagely profit driven. In Chicago its becoming easier and easier to find long-term placement for very poor 50+ year old mad persons simply because the nursing homes have figured out that by providing minimal levels of care they can bleed out extra money from the State by using up a patient’s “skilled nursing” days.

    If we spent more money, and spent it more sensibly, nursing homes like that wouldn’t exist. But thats the cold logic of what improving care for chronic patients comes down to: we need to spend more money. A lot more. Instead we’re seeing the minimal services out there shutting down to pay for cops and DMV goons to get obscene pensions. Thats the choice we’ve made, and it means people rotting in beds, dying on the street, or going to jail instead of the doctor. Its ugly, and stories like the one Jill linked muddy the waters enough for us to imagine that we aren’t completely failing these patients, but its the reality of what happens when we decide to treat mad folks as lepers.

  14. I’m sure others have noticed this before, but one thing that really stood out to me about this article is the way that all the laws mentioned about outpatient commitment are named after people who were attacked by mentally ill people, not people who suffer(ed) from mental illness. Says a lot about the way people with mental illnesses are seen, and then of course that gets translated into the way they are treated.

  15. As a severely mentally ill person with a severely mentally ill grandmother, I thank you for your work and your perspective, William.

    Karak86, if you don’t value the mentally ill, it’s a good thing you found another job. It’s ironic that you seem to want sympathy for your panic attacks but can’t extend it towards people with more severe mental illness.

  16. A suicidal person gets 24 hrs hospital observation here. Not suicidal? On the street. Most rural areas have NO options except medications.

  17. Focused, yeah, but I’m not going to pretend that being crazy isn’t a burden for everyone in my vicinity either.

    I get that, I really do, god knows mine has been and I know that some of my patients families have had hard rows (although family therapy tends to reveal that things are a lot more reciprocal than anyone wants to admit). Still, if therapy is going to work it has to be about the patient, not about the people around them. Its kind of a hardline stance, but my position is that I simply cannot serve more than one person’s interests. That means that I cannot allow myself to worry about the concerns or tribulations of their family, I just can’t, its a conflict of interest and I won’t do that to a patient who has likely already experienced a lifetime of trust violations and people pretending to be their ally in the name of making others more comfortable.

    Karak86, if you don’t value the mentally ill, it’s a good thing you found another job. It’s ironic that you seem to want sympathy for your panic attacks but can’t extend it towards people with more severe mental illness.

    I’m all for raking bad providers over the coals and hounding them out of the business, but I think Karak deserves some sympathy here. They job they’re describing is a meat grinder with very few good options in which even the most caring individual is pretty much guaranteed to do a bad job because the resources simply aren’t there. Its a world of intolerable options where burn out and vicarious trauma are not questions of if but of when. What Karak was describing didn’t strike me as a lack of sympathy for patients so much as a complete lack of ability to make sense of the utterly senseless systems so many of us have worked in. I’m one of the more aggressive proponents of mad folk’s rights that you’re likely to encounter and even I don’t have a good answer about how to deal with a patient who gets to the point of their body literally rotting (I’ve seen that, too) because they are unable to care for themselves and unwilling to accept help. In those cases I step back and accept that there are limits to what I am personally capable of achieving and that this is the cost of a radical commitment to autonomy and personal sovereignty above all else. 99% of the time that is enough, and more often than not being able to take that step back and remove your own values in the name of a patient’s autonomy is healing in itself, but that 1% fucking haunt you. That doesn’t mean that the 1% should have fewer rights, it doesn’t mean that we should bend the rules to make ourselves more comfortable, but there shouldn’t be any shame in someone taking a step back and saying that they just can’t deal with that 1% in the back of their heads for the rest of their lives. Not everyone is cut out for this.

  18. Karak86, if you don’t value the mentally ill, it’s a good thing you found another job. It’s ironic that you seem to want sympathy for your panic attacks but can’t extend it towards people with more severe mental illness.

    That’s an incredibly unfair and mean-spirited interpretation of what Karak posted. Get back under your bridge.

  19. I’m not trolling, amblingalong. It’s actually a pained interpretation. What Karak had to say was very cruel. You really have no place to tell me how to take ableist attacks. Seriously, I’m mean because I’m not enabling viciousness?

  20. What Karak had to say was very cruel. You really have no place to tell me how to take ableist attacks.

    samantha, I read that as Karak speaking about their inability to handle the stress of the job and the lack of support/benefits for people doing it in general, rather than a statement about the value of mentally ill people.

    And frankly, mentally ill people require fairly large amounts of emotional energy from their caregivers. Of course, that’s only if said caregivers are interested in not being raging douchebags to the incredibly vulnerable people in their charge, but it sounds like Karak was.

    I mean, I have a relatively minor and unimpactful (on others) mental illness, an anxiety disorder, and it still has tangible negative effects on people around me. Handling me logically, compassionately and effectively when I’m in total crisis mode is a significant strain on my wife, and I can’t imagine that she’d be able to handle my being in crisis mode all the time at much higher levels (much less five or six more like me) without any support. This doesn’t mean she thinks I’m valueless by a long shot, or that I think she’s undeserving of the effort and understanding it takes me to handle her clinical depression.

  21. My unhelpful comment is this:

    There is still a class of people who can be put in institutions against their will quite easily: minors. I have seen this happen. It was horrible. There is a difference between support, help, and treatment, on the one hand, and the stripping of all rights and control over your body and your life in a way that will follow you the rest of your life, on the other.

    We live in a society that is eager to solve problems by stripping some of its members of their rights. Terrorism? Well, let’s have the Patriot Act and round up a lot of Muslim men. Drug addiction? Three strikes and you’re out. Mental illness? We’ll just make those people do what we want them to. That’s a fucked up paradigm, and until we stop using that as our go-to solution for almost everything, we will not get closer to finding out how to really help people who need a greater-than-average amount of support to take full pleasure in their lives.

  22. @samanthab:

    My mother is manic-depressive. This isn’t about the inability to have compassion, it’s about the fact there’s nothing that can be done for some people. Drugs, therapy, cruelty, kindness, commitment, treatment facilities, family, subsidized housing–nothing keeps them from being symptomatic, from being self-destructive.

    I had no idea what to do with some of clients. They needed help, but I had no power to give it. I have no idea even what they needed from me, but it was something. And soon I realized that every bit of myself was being given to people that I wasn’t helping at all.

    I currently work with kids with minor mental health issues and major behavioral issues. Except now my caseload is zero. I go in to work for eight hours in a live-in treatment facility and help them. I play with them, talk to them, listen to their problems and find solutions, if I can. If nothing else, knowing I hear them and I care is something.

    Once I lost the giant caseload and got into a field where I was actually helping people I was much better emotionally and at my job. I was watching people slowly drown before, now I’m helping people out of the pool. But will I ever go back to working with people with chronic, profound mental health issues? No. I’m completely burnt out.

    @William–I believe we talked back and forth a while ago about our experiences in the field before.

    I think there are not a lot of people who can handle dealing with seriously symptomatic people; people who draw on the walls in feces, viciously attack orderlies, scream and sob for hours, have bizarre delusions or hallucinations, dig out their teeth… most people purely can’t handle it. I think there are a lot of people that feel fear or disgust about the mentally ill, yes, and they can be taught compassion. But the number of people who can watch someone draw on the wall in poop on Monday and then eat lunch with the same kid Tuesday is pretty damn low. And I think there should be a 1-1 or 1-2 ratio, staff-to-client. And I just don’t think the numbers work out.

  23. If I were talking just about myself I’d post under my usual handle, but I want to talk about family too.

    —

    Oh, my goodness, I have such mixed feelings about this.

    A few months back, I did a project on deinstitutionalization for my psychology class — a 30 minute lecture to the class. I ended with the “big reveal” that I was, in fact, bi-polar/manic-depressive, and that I had been hospitalized four times. I told some stories about what I’d seen of the system with my own eyes. I did this in part to counteract the professor who had been telling “funny stories” about his time working at the local inpatient facility (a place I had been not six months before). It went well. But the experience itself produced burnout, because the resources available to me as I prepared this project were books written by psychiatrists, social workers, or families of the mentally ill — and being mentally ill and reading about how fucked up society thinks you are can be upsetting.

    ==

    My first experience with psychiatry came when I was twelve years old, and my mother overdosed on prozac and had to have her stomach pumped. She was in patient for perhaps three weeks; then she came home and continued to be violently depressed and a raging alcoholic. She’d attempted suicide because she wanted to keep her pregancy, and her parents (one of whom is a child psychiatrist!) and her husband wanted her to abort. When she overdosed, she miscarried.

    My adolescence sucked. I hated my mother because she was drunk and abusive. I used to fantasize about pushing her down stairs. I told myself I would never, ever, ever be like her.

    And then I got ill. First “a little bit” ill, and then I was at the point where I was not emerging from my dorm room for a week and lying in my own filth. Eventually I accepted treatment — I saw, of all people, my FATHER’s counselor for cognitive-behavioral therapy. It was the summer, and seemingly of its own accord my depression lifted. My pediatrician (I had just turned eighteen) put me on an anti-depressant, and I delt with the remnants of the anxiety and depression. When I went back to school, I went off drugs and considered myself “cured”.

    And then it came back. And it came back hard. I began to self-mutilate; I began to think of suicide every night. I had no idea how ill I was — I had no idea how to quantify my misery, how to put it into perspective. It would take years of cycling through depressions and occasional, brief, mild and glorious manias to learn how to gauge my moods. I am still learning.

    That thanksgiving I saw my old counselor (my father had quit therapy because, in his own words, “therapy is bullshit”) and told her I wasn’t doing well. To my surprise she fixated on my lovelife, which admittedly wasn’t great but I didn’t think BDSM was that important comparitively. She, however, called my family without my permission and brought them into her office. She made me describe my sexual experiences in front of my father and then told him that I needed to be in patient. I refused; we went home; I went back to school – and I’d been back for a day when my parents (both of them) flew down to the college I was attending and told me that unless I flew back to my home state to go to the hospital they’d chosen for me there, they’d cut me off and I would be homeless. Apparently my counselor had told them that if they didn’t, “I’d be dead within six months.”

    —

    My first experiences with psychiatry, then, were:

    A) It doesn’t work – my mother was depressed for ten years throughout her treatment, and abusive on top of it;
    B) My father thinks it’s bullshit;
    C) You can’t trust anyone;
    D) Once you get a label, people can force you to do things against your will.

    I used to have nightmares about being hospitalized — nightmares worse than the ones I had after I was raped. Actually, I had nightmares about being raped by the psychiatrists and other psych people at the hospital.

    ==

    I have been inpatient three more times, the second and third time voluntarily, the fourth time… I was so depressed that if you’d told me to sign my name to a form stating my eternal loyalty to the King of Transylvania, I probably would have.

    I have been to swanky private hospitals and to overcrowded state hospitals. I have been kept for weeks on end when I was insisting I was better, and discharged after two days when I was begging for more help. I have seen people who needed help badly refuse all treatment, and people who were begging for help discharged to a bus station with ten dollars and three days worth of meds, told to go back to the homeless shelter they’d been at previously.

    ==

    I do not disagree that it is stressful for family members to live with mentally ill family. I’ve BEEN THERE (given that mental illness runs in families, I would imagine MOST of the severely mentally ill have “been there”). I get caregiver fatigue, I get it. But I’ve faced a lot of abuse (as has my mother) for being ill, for being unpleasant and difficult and tiresomely ill.

    The system is not set up to work for the best interests of the patients. It doesn’t seem to be set up for the best interests of the families either. It doesn’t seem to serve the public interest very well. Who is it serving? Or are we at a point where chronic lack of money means the system’s purpose is incoherent and its outcomes unpredictable? I think so.

  24. It doesn’t seem to serve the public interest very well. Who is it serving?

    I’m not so sure I agree that the system doesn’t serve a public interest. It might be monstrous, but the system we have today is very good at systematically disempowering and dehumanizing mad persons, subjecting them to escalating elements of power, and devaluing non-normative experiences. By treating mad folks the way we do we ensure that the locus of the problem is seen as being within them which, in turn, ensures that we don’t have to think too much about how they came to be mad. I think thats a big part of the push for biological understandings of madness: biology is just the way things are, nothing to see here, please move along. Psychoanalysis, on the other hand, questions and pursues. A lot of people benefit from the way things are.

  25. William, I have to say I’m a little surprised at this:

    “I think thats a big part of the push for biological understandings of madness: biology is just the way things are, nothing to see here, please move along. Psychoanalysis, on the other hand, questions and pursues”

    Which seems to imply that finding biological underpinnings to MH diagnosis is a dead end? As if, (if) once a biological cause or contributor is found, then nothing happens with that information and treatment stops? It also seems to set up an either/or that there is no reason to presume; it’s entirely possible if not probable that a MH diagnosis would have both biological components in the form of predispositions & vulnerabilities as well as environmental triggers or contributors. I can’t think of any complex human traits that aren’t a blend of “nurture and nature”, so why would brain functions be any different?

    Am I misreading this, or reading into it things that aren’t there?

  26. IrishUp:

    I don’t deny that there are biological factors at work, but I am deeply suspicious of the medical model when talking about madness and I feel that, more often than not, good (and often bad) neuroscience is used as a tool for short circuiting meaningful and nuanced understanding of madness in favor of convenient, politically expedient solutions.

    When I was working at a large, publicly funded, urban hospital the adult outpatient psychiatry department had 5 or 6 psychiatrists to manage all of the drug maintenance for thousands of patients. That same department had only three psychologists, one of whom only did neuropsych testing. The only way anyone had any access to therapy was a robust training program that had under a dozen graduate students working 20ish hours a week. When a scandal broke the training program was abolished and therapy just wasn’t an option for the department in the same way it had been before. Drugs were still there, but psychotherapy services were no longer a priority. Most of our patients were indigent (we used to give out bus passes so they could afford to come to therapy, until that funding dried up) and didn’t have another option. Private community services were non-existant, non-profits were stretched to their limits, and community mental health center were already over utilized and underfunded. Thats the medical model in action, thats the problem with a biological viewpoint. Psychotherapy becomes a devalued luxury while a third gen atypical antipsychotic with a long track record of serious side effects becomes the default (and only) treatment available.

    I’ll also come right out and say it: biology is only going to take you so far. Madness, especially the most common problems we see today, almost always has a very large experiential component. Psychotherapy, especially psychodynamic therapy, not only works but works better than even the best drugs we have available. Madness is a product of experience, the cure also needs to be one of experience. You can take a behavioral approach and talk about learning, you can be Rogerian and talk about actualization, you can think about object relations or defenses, but at the end of the day the human mind is a lot more than the meat which contains it. Even a wonderful binding is ultimately dwarfed by the content of the words within a book.

  27. Just putting it out there. I was involuntarily committed for a week for, in essence, crying too much.

    I wish I were lying, but I’m not.

  28. @William, thank you for explaining more fully. Your objections to the medical model (as you put it) make perfect sense to me.

    I do come from an orientation where I think a lot about the genetics/biology of mental health. But I am equally wary and suspicious when the only treatment is medication. I am just not sure we can lay that @ biology’s door; I see it as a systemic problem with how marginalized people are treated and how atypical or poor mental health is stigmatized in a way that atypical or poor liver health (eg) is not. In that sense, this “medicate it” and eschewing therapy attitude both predates the neuroscientific advances and is part of a larger problem.

    And on the converse side, interpersonal therapy can only take you so far. Someone who is having a psychotic break, or is demented or delusional, or has a toxic encephalopathy, isn’t going to be *able* to benefit from IPT while in that state. And medications are frequently needed to reverse or ameliorate those states.

    OT; The historical and current abuses of the mentally ill are simply egregious. My maternal grandmother was subjected to many of these. My father worked inside several psychiatric hospitals and even in the (ahem) modern age, there is some hair-raising shit that goes on. OTOH, having been through a similar process as the author in the NYT piece for 5 years for a different diagnosis, I can ALSO attest to the fact that we’ve seen services denied because AUTONOMY, and seen direct, personal, and violent harm come of it.

    Navigating the DMZ between doing something TO someone for other people’s REASONS!, and doing something FOR someone that they would want if they were functioning better, or will appreciate later is tricky stuff. FRAUGHT is a better word. But it’s not being adequately addressed at policy levels, and it’s for DAMN sure that resources, funding, and supports are lacking to address these needs. But IMO, there HAS to be a better way to do this than institutionalize and involuntarily treat behind door one vs allow people and families to remain in limbo at risk for harm until the other shoe drops behind door number two.

  29. IrishUp:

    And on the converse side, interpersonal therapy can only take you so far. Someone who is having a psychotic break, or is demented or delusional, or has a toxic encephalopathy, isn’t going to be *able* to benefit from IPT while in that state. And medications are frequently needed to reverse or ameliorate those states.

    You’re only partially right. I’ve seen psychodynamic therapy do very well with patients who were actively psychotic and there is a very long history of that kind of work. Psychotic depression isn’t all that uncommon and I’ve personally been involved in multiple treatments where medication didn’t take the edge off the psychosis (it was more for the suicidal ideation) but therapy did. GIFRIC/388 Center for Psychotics has done some very good work as well, with Willy Apollon doing some incredible writing about what they’re doing from a Lacanian perspective. Organic disorders obviously won’t improve from talk therapy, but psychotics have been in successful treatment from the beginning. Its harder, sure, but its far from impossible.

  30. Very cool, William. As usual, thanks for taking the time & providing more info to follow up on.

  31. You’re very welcome. GIFRIC is especially interesting because they’re doing traditional Lacanian psychoanalysis, not just psychodynamic therapy. Its well into the realm of the analysts and pretty far from what we’d call science in the US, but its very difficult to argue with their community reintegration rates…

  32. We need to work on preventive measures. Spend some time studying children who have just learned how to talk. They copy everything the parents do.
    By the time they are three or four years of age they are already developing habits. Now, combine the two, coping an adult and habits before they start school.
    These children are learning to do things which will lead them down a dark road should they ever start thinking about things they cannot change about their life.
    When I sit down to talk with people living with one or more mental illnesses, its clear to see just how bad their habits are and how much time they spend doing things which are very close to how their parents did things.
    The problem with this situation. The person will never find their true identity. We don’t have family traits. Its all habits created from copying our parents.
    For two hours a week of nine months listening to people talk, I noticed how they lived each day based on habits. What do habits do for you? They allow you to live with your illness and still live or survive without having to think about what you are doing. The illness takes over while you are stressing over something not related to the illness.
    Parents have to be more responsible by paying close attention to their children. Spend as much time outside by getting into nature. A person can change in a day. Nature takes 100s or 1000s of years to change. This creates a warm comfortable feeling for the person when they are adult. All they have to do is go outside and get into nature and the childhood feelings will come back.
    A couple of people in the group actually got better when they used my “The Five Sense Therapy” How it work, using the five senses, a person will need to find one new thing to explore each day with one of the five senses. It works great for people living with depression. A few months later, a girl told in the group said. Its been four years, but, I dating again. This type of therapy is free to very low cost and it helps stimulate the brain.

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