Friday, April 27, 2007

Political Beef: Mental Illness

I was planning several additional posts on my "Political Beef" thread, beginning with a tirade on the stupidity of our nation's political stance on mental illness. But then, novelist and psychologist Jonathan Kellerman wrote this opinion article, which really stole my thunder.

Having worked with the mentally ill for the year of my adult life in which I think I learned the most; having talked extensively with others, including my mother, who work in that field; and having more than one case of mental illness in my family, I have seen close-up our country's failure to address the needs of the mentally ill with justice, kindness, and wisdom. I wanted to discuss this before the tragedy at Virginia Tech; even more so now.

What Kellerman writes is, in my experience, dead-on. I spent a year working as a case manager in an outpatient program for severely mentally ill adults. In my service to the mentally ill, I was continually frustrated by our society's inadequate measures to prevent the tragedy and heartbreak that can befall the mentally ill and their families. I was frustrated by the uncaring pragmatism of Medicaid, Social Security, HUD, HMOs, local law enforcement, and the justice system. I grieved and struggled when, over and over and over again, patients were discharged from a hospital and immediately "decompensated" and had to go back in; when disabled people with no income were unable to collect their SSI benefits because they needed representative-payee services that no one could or would provide; when clients dangled and twisted on a months- or years-long waiting list for public housing, residential treatment, group homes, etc., only to be thrown out soon after placement because of the very behavior that had gotten them in trouble in the first place.

Patients were arrested for behavior caused by their illness, treated as criminals, and sent to jail where they were cut off from treatment; their condition spiraled out of control, creating a vicious circle of aberrant behavior, extended punishment, and further decompensation due to lack of treatment. Patients were put on probation even though they were too disabled to meet the requirements of probation, leading to more trouble with the law. "Independent living" patients were housed in inadequately staffed sites where they scared the neighbors, sued each other blind, and shared drugs, beds, and wasting diseases with each other. Patients lived in terror and despair, some of them fighting every waking hour against the voices in their heads until they didn't have energy enough for anything else; whilst day programs that could give them some relief and supervised social contact (and that could give a break to their caregivers at home) were being restructured to exclude the people who really needed them. Patients were passed around like hot-potatoes between programs that could only deal with some, but not all, of their co-occurring problems (such as mental illness and substance abuse and homelessness). Patients who had personality disorders, or who should have been diagnosed as developmentally disabled when they were younger, were screwed to the umpteenth power.

Patients were routinely discharged from hospitals before they were really stable, on the orders of "resource utilization" personnel (i.e., HMO lackeys) who applied the flimsiest imaginable criteria for discharge, resulting in almost immediate decompensation and re-hospitalization. Patients were confused and distressed because outpatient doctors and staff treated them as if they should understand things, and be able to do things, which they could not; and so totally unqualified, non-clinically-trained case workers (like me) had to be hired to maintain the link between the patient and his clinical care; which basically made us case workers the people most intimately familiar with our clients' lives. It also made us the only people dedicated to arguing "Yes!" when every other agency and service-provider was briefed to argue "No" until every conceivable reason NOT to help had been exhausted.

Some examples of what I mean may come up in future posts on my "Stupidity" thread; they'll make you wonder whether to laugh or cry.

And the stupidest thing is, it's getting worse. Nebraska, where my Mom works in the behavioral health system, is phasing out its state hospitals and replacing them with "community-based treatment" programs, which will mean: (1) more hunger and homelessness; (2) more substance abuse, a.k.a. self-medication; (3) more slumlords collecting mentally ill tenants who then proceed to spread hepatitis and AIDS like wildfire; (4) more crimes perpetrated against and/or by the mentally ill; (5) more seriously disabled people left to their own devices, without the mental equipment to connect themselves with the social services they need; (6) more behavioral-health outpatients missing appointments or going off meds and getting sicker; (7) more inmates the criminal justice system isn't equipped to handle; (8) more suicides that could have been prevented; (9) more families worn to the bone by the burden of caring for severely ill loved ones; and (10) in the long run, a higher cost in tax dollars and insurance claims, when all the additional trips to the emergency room, state hospital, courthouse, jail, prison, and other expensive programs, that could have been avoided by treating severely ill individuals in a safe, stable, humane asylum, are totted up.

Kellerman is so dead right. I mean, I had chills when I read about his prof's vague anecdocal "evidence" about Belgian farmers taking discharged aslyum inmates into their homes. When my family lived in rural Nebraska, which followed a similar model, we took in a discharged patient, and he ended up splitting up my parent's marriage and becoming my late stepfather. And my mother, while working full-time in the state hospital caring for people who really, really need to be there, came home every day to care for a husband who eventually needed 24/7 supervision. Do you think I would willingly see her go through that again? Why should I wish it on anyone else? Much less the millions of people who will endure that, or worse, if Nebraska - and other states - continues to follow the "liberationist" trend Kellerman so ably exposes. It is to NO ONE's advantage to do this. It is stupid; it is hateful; it is harmful; and it is wrong.

In his conclusion, though, Kellerman seems to despair of being able to fix these problems. I think there may be some solutions, but they will be slow to happen at best. One solution is to work on ridding people of applying a "social stigma" to the mentally ill and those associated with them. Superstitions, stereotypes, and urban myths about mental illness need to be busted; such as the idea that schizophrenics are more violent than the average mentally-well person (in fact, the opposite is true), or that they are stupid people who have mostly gotten that way because of something bad that they did, or that they are mostly malingerers, drug-seekers, system-users with an "entitlement" mentality. You do see that sometimes. But you can't blame people for having an "entitlement" mentality, when their "entitlements" are the only cards they hold. People need to be better informed about what mental illness is, how to know it when you see it, what kind of help to look for, and how to know whether or not you're getting that help. And then, of course, the public should be encouraged to support government funding, and mandates, for research and treatment based on clinical evidence - not vague anecdotes and politically-correct platitudes!

At the very least, our society's response to mental illness should be in proportion with the number of people who suffer it and the depth of their suffering (often leading to death from a variety of causes). Statistically speaking, you probably have someone in your family who is mentally ill, perhaps even severely so. So you know the suffering of which I speak. If all the people suffering from mental illness, or caring for those who suffer, would speak up about what they are going through and what they know needs to be done, their voice would be heard. And since they are probably too busy, too tired, too poor, and too humiliated by the aforesaid stigma, it is up to the rest of us to lift up our voice in their stead.

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