Numerous articles, books, and newspaper editorials have been written about the “crisis” in mental health care in our country from various perspectives, and the phrase is often used that the mental health system is “broken.” It seems that lately, this topic is often brought up after the most recent mass shooting.1
Dr. Otto Kausch
Philip T. Yanos, PhD, correctly asked recently whether we should be talking about a “broken” system, because implicit in the phrase is the assumption that the mental health system was once “whole,” and he has pointed out2 chronic deficiencies, such as the absence of affordable housing, and the availability of services to those with chronic mental illness.
In addition, many authors have asserted that, with deinstitutionalization – which occurred starting with the Community Mental Health Act of 1963 – homelessness also became a big problem for people in our prisons and jails, which became the default treatment providers for many of those with serious mental illness.Once authors make this point, they often offer up ways to start addressing various parts of the system, and it usually comes down to asking for more funding for more outpatient treatment and services as well as more inpatient beds. Some authors make the point3 that people with mental illness often lack insight into their illness and the need for treatment. Thus, we have the quandary of people with severe mental illness not believing that they need help, and thus not even trying to access services, which can lead to homelessness and jail time.
But what of those individuals with serious mental health problems who aren’t facing those obstacles and complications? What about individuals who aren’t facing homelessness, who haven’t gotten embroiled in the legal system, who do have insurance coverage, who live in areas with sufficient numbers of outpatient mental health centers to choose from, and who have no problems finding an inpatient bed when needed? Let’s suppose that we have an individual who does have insight into his mental illness and need for treatment, and is motivated to seek treatment. How responsive is the system to such individuals? That will be the focus on my article.
In a recent report,4 the author quotes American Psychiatric Association President Bruce J. Schwartz, MD, appealing to members of the U.S. Congress to step in. According to the author, Dr. Schwartz’s position is that the crisis in American mental health begins specifically with a drastic, and growing, shortage of psychiatric beds, especially in publicly funded state and county hospital beds. From there, the crisis spreads to the nation’s city streets, and its jails and prisons, where the largest number of people with serious mental illness now reside. He also talks about a shortage of psychiatrists and child psychiatrists, and says the shortage is likely to worsen. The proposed solution to this problem, of course, is more funding from Congress to open more psychiatric beds, as well as providing more funding for mental health in general and funding to residency programs to increase the numbers of psychiatrists.
I respect the opinions of Dr. Schwartz and that of the other authors who want to talk about lack of adequate beds, outpatient clinics and services, insufficient numbers of psychiatrists, and a lack of funding by Congress. However, I would like to provide further information, from a personal perspective, which causes me to believe that the problem is even more complex than that, and that the failures of the system are compounded by a dysfunctional culture within the ranks of professional caregivers. In other words, once the pieces are in place and assembled, the mental health system still seems to be “broken” but from within. I worry about apathy and an absence of motivation to provide good or even adequate services by the very people who are or should be aware of the problems and what it takes to help our vulnerable patients lead better lives.
I have practiced psychiatry for many years in various settings. I have spent many years working as an inpatient psychiatrist in a large state hospital. I have worked in community mental health outpatient settings. I have also worked in a private practice doing both inpatient and outpatient patient care as well as significant forensic work. At the hospitals, I have witnessed and prepared internal reports about patients who are “revolving doors.” Such patients often had more than 50 psychiatric hospitalizations and no apparent solution to keep them stable enough in the community.
But mental illness is not just a career for me. In addition to being psychiatrist, I am the father of a son with severe and persistent mental illness. I have watched him struggle to find stability. He, too, has been in and out of hospitals. My wife is also in the mental health field. She and I have endlessly tried to work with our son’s local community mental health center to provide them with feedback and to get them to respond to his needs – often with great frustration. It has been our impression that clinicians have difficulty listening to us and understanding the difficulties our son is having, from my son’s case manager to the treating psychiatrist, to the director of the agency. We have tried shifting him to other programs in a neighboring county, including one known to be a “model” program, but had the same issues.
Psychiatry is more of an art than science. Our other medical colleagues can try to resolve a clinical problem, no matter their rank, by ordering the right blood test or getting certain imaging. Psychiatry has no such biomarkers, or validated tests, to rely on to resolve disputes. We have only our training and experience and, unfortunately, our biases. If we don’t agree with a colleague, we often resort to rank and argument.
Psychiatrists (just as can colleagues in other specialties) can be insufferably arrogant.
My personal experience has been that the hospital and the community often don’t communicate well. This seems to be a systems problem, as is the case for many complex unsolvable problems. I have been to discharge meetings involving hospital staff and the receiving community system. The attitude of the inpatient psychiatrist is often: “If you guys only did your job better, this patient wouldn’t keep having to be admitted. It’s your job to keep him out of the hospital.”
Alternatively, the community rejects this attitude and points to the absence of resources that prevents them from seeing patients in a timely manner and from adequately monitoring them. They say they are shackled by their resource constraints and that the endless admissions are inevitable. Further, the outpatient psychiatrists complain bitterly that all the inpatient doctors do is make a bunch of useless medication changes and then don’t keep patients in long enough to make sure the patient stays well. And on and on the arguments go with no resolution.
Sadly, and confirmed by my personal experience, when well-meaning and knowledgeable family members try to communicate with the community mental health system about their son’s mental disintegration, the community agency often doesn’t welcome the feedback. They resort to “confidentiality” concerns, often ill advised. Their opinion seems to be that the patient, (i.e. the patient who is falling apart and is becoming psychotic), should be the one calling the agency, waiting on hold forever, and not getting a call back. When my son has been in this situation, he has hung up his telephone out of frustration, then headed off to the emergency room, where he knew he would be seen.
The other area of frustration is that of the ideal of recovery. Mental health programs love to tout that their mission is “recovery,” and they list it as one of their primary areas of vision and goals. Yet, when we tried to communicate with community clinicians, they usually ignored our request to assist our son with supported employment and to help him achieve independence and a social life. When we tried to convey our recovery concerns to the psychiatrist, the usual response was also to ignore it and focus on “meds, meds, meds,” which most psychiatrists seem to view as their mission and area of expertise. Many psychiatrists have embraced the “bio-bio-bio” model of evaluation and treatment5 with only lip service paid to the “biopsychosocial” theory they like to say they advocate. When we reached out to our son’s psychiatrists and could get through, we found that they mostly failed to display much interest in paying attention to broader areas of functioning, instead focusing on symptoms, which they could observe in person.
So, I add to the chorus complaining that our mental health system is broken. Broken not only in terms of adequate funding, but also broken from within. It would require much wisdom and self-examination to even begin to address the problem. Without a better plan, throwing money at this broken system won’t improve the lives of our seriously ill and vulnerable psychiatric patients.
Dr. Kausch is a clinical and forensic psychiatrist who is on the faculty at Case Western Reserve University in Cleveland as an assistant clinical professor. He spends most of his time seeing patients through the Akron General/Cleveland Clinic health system. He has published in the area of forensic psychiatry, addictions, pathological gambling, and suicide. He has recently taken an interest in conducting marital therapy and is now publishing in that area as well.
References
1. Doroshow D. “We need to stop focusing on the mental health of mass shooters.” Washington Post. 2019 May 20.
2. Yanos P. “Is the mental health system ‘broken’?” Psychology Today. 2018 Oct 11.
3. Orenstein N. “How to fix a broken mental health system.” The Atlantic. 2016 Jun 8.
4. Moran M. APA rings alarm in nation’s capitol about crisis in mental health care. Psychiatr News. 2020 Jan 1.
5. Paris J. “Psychotherapy in an Age of Neuroscience.” New York: Oxford University Press, 2017.