Our mental health crisis

John F. Kennedy was one of our most visionary presidents. He set a ten-year goal for landing on the moon and, although he didn’t live to see it, the goal was met. He envisioned an agency, separate from the State Department, that would give American citizens the opportunity to live and serve as volunteers in developing countries around the world; and the Peace Corps became a reality. He envisioned, and provided funding for, a national mental health system, made up of local mental health centers, to replace the system where most mental health treatment was provided in large, centralized state institutions.

For most of my career as a psychologist, I was employed at community mental health centers (CMHCs). Little did I know when I started out in 1976, working for a CMHC in rural Alabama, that these were the halcyon days of our national mental health system. Mental health agencies had adequate funding to meet community needs. The plan was to decrease reliance on expensive (and often unnecessary) inpatient treatment in state “mental hospitals,” by providing outpatient mental health services at the local level. Almost all of the initial funding was federal dollars, with the understanding that the federal funds would gradually decrease, and states would allocate a portion of the money saved, to replace the federal funding for community outpatient treatment. The goal of the well-intentioned plan was called “de-instititutionalization.”

All across the country, states made plans to eventually shut down the massive institutions that often “warehoused” patients with chronic. severe mental disorders. This saved the states a lot of money over time, but the state legislatures failed to carry out their part of the plan and replace lost federal funding for community mental health treatment with state dollars. Instead, the money saved went straight into state general funds, and funding for community treatment gradually diminished, year after year. The range of services provided shrank over time. Community outreach and support services programs closed down and CMHCs became understaffed. Clinicians (like me) initially hired to provide individual, family and group therapy found themselves doing less therapy, and more and more bare-bones case management services for their ever-increasing caseloads of underserved clients. A lot of seriously mentally ill people received only occasional fifteen-minute medication management sessions with a psychiatrist.

With the big, centralized institutions shut down or downsized, and with the inability of most CMHCs to adequately meet community needs, across the country more and more people with mental illnesses and substance abuse problems have joined the ranks of the homeless. In many cities, hospital emergency departments stay backed-up because of all of the severely mentally ill people who need treatment and can’t get it elsewhere. Jails and prisons have become primary providers of (often inadequate) mental health services. Often, police officers are the first point of contact with people who are psychotic and out of control, sometimes with tragic results.

Few police officers are adequately trained to do effective interventions with manic and psychotic people. If the states had done their part and adequately funded community-based treatment, and we had the national mental health system that Kennedy envisioned, the first responder in a psychiatric crisis situation would be a social worker or a psychologist, not a cop. Police have enough responsibilities, without having to respond to psychiatric emergencies. Jails and prisons have enough problems to deal with, without having to be de facto mental health centers. Jails and prisons are obviously not environments conducive to stability and recovery.

Mental illness and substance abuse are some of the root causes of the rise in homelessness, and too many Americans are more judgmental than compassionate when they encounter homeless people. There remains in our society a stigma that brands mentally ill people as the Other, not as individuals whose impairments should be recognized and addressed on a societal level. Our national mental health system is a disgrace, partly due to stigma and the consequent marginalization of people with mental illnesses and substance abuse problems. We need to elevate our compassion for these people to the level of our compassion for people suffering from cancer and other physical diseases – maladies that have ad campaigns promoting awareness and compassion We need to treat substance abuse as more a public health issue than as a criminal issue.

Prevention is a vital part of medicine, and gets a lot of attention when it comes to physical illnesses. Kennedy’s plan emphasized prevention, and we need to develop a national model that puts the treatment of mental illness and substance abuse on a par with the treatment of physical injuries and diseases.

Who is mentally ill?

Sometimes as the group leader in my psychoeducational groups, I’d start my standard rap on psychopathology by writing two words on the board: sad and depressed. Then I’d ask, “Do these two words mean the same thing?” After listening to responses from group members, I’d proceed in this manner: Yes and no. On the street they’re synonymous, but to a psycho-diagnostician they can be very different things. Sadness is a universal human experience. Sometimes we can identify the reason or reasons for our sadness, other times not. When a person says, “I’m depressed because my friend is moving away,” they’re likely describing “normal” sadness that will probably diminish over time.

Sadness is a mood, and moods come and go. If a sad mood becomes persistent and affects your functioning, depression may be a better description for the experience. This persistent mood may also be due to an identifiable cause, such as a romantic breakup, or it may be unrelated to life circumstances. The former is referred to by some  clinicians as “functional” (caused by some external circumstance), the latter as “endogenous” (caused by internal, biologic factors). This isn’t an absolute distinction in all cases, but it has its utility.

There’s a deeper level of depression that isn’t a universal experience. Even at the lowest points of my life, I’ve never been as sad as the clinically depressed people I’ve known personally and professionally. People living with this kind of depression may experience hopelessness, despair, and suicidal ruminations. I’ve never been there, and I have great compassion for those who have.

One way of classifying psychopathology is assigning people to distinct diagnostic categories. You either do or don’t meet the diagnostic criteria for depression, or schizophrenia, or bipolar disorder, or antisocial personality disorder. If you don’t have the disorder, you may have traits associated with it. Another way of classifying pathological traits is to view them along continuua: straight lines with opposite poles. Everybody can be placed somewhere on a continuum between happy to be alive and suicidal, gentle and violent, honest and dishonest, paranoid and trusting, and other traits and tendencies.

If I’m extremely unconventional but functional, some people may refer to me as “crazy,”  but to others I’m merely eccentric. If I’m unconventional to the point I can’t function in society and may endanger myself or others, I could be mentally ill. In my graduate program in humanistic psychology, we didn’t even have a course titled “Abnormal Psychology”; that was considered too pejorative. Our course was titled “Unconventional Modes of Experience,” lest we apply unnecessary or judgmental labels to people.

Psychopathology is characterized by impairment or disability. I have obsessive-compulsive traits, but I don’t think of them as pathological, because I’ve been able to recognize, control and channel them. I’ve had doctors and lawyers tell me that they never could have made it through medical school or law school if not for obsessive-compulsive traits. You too may have traits of a mental disorder, but not meet the diagnostic criteria, because you’re not impaired by them. For instance, you might have some symptoms of depression, but not be pathologically depressed. Or you might have paranoid traits,  but not be diagnosable as having a paranoid disorder. The hyper- vigilance characteristic of a truly paranoid person might even be desirable, if you’re a spy.

Even if you have a diagnosed mental illness or engage in crazy behavior, you can’t be involuntarily committed to a treatment facility without a Probate Court hearing. (I only refer to behaviors as “crazy,” not people.) In most states you must be interviewed before the hearing by two Designated Examiners (DEs), one of them an MD, and have court-appointed legal counsel to represent you at the hearing. In order for you to be involuntarily committed, both DEs must agree – and convince the court – that you are of danger to yourself or others, due to a diagnosable mental illness. I’ve had the privilege and responsibility of being a DE for most of my career, and in my experience the system works most of the time to prevent people from being “railroaded” onto locked wards against their will.

Mentally ill people are often shunned, and even blamed for their symptoms. With good treatment most mentally ill people can function in society, although some are too disabled to hold a steady job. All people with mental and emotional illnesses deserve good treatment, regardless of income. But unfortunately, state mental health systems all over the country are terribly under-funded, and many folks don’t get the treatment they need to remain functional. A significant portion of homeless people have mental illnesses. Hospital ERs, jails, and prisons have become major mental health service providers. I’ll describe how we got to this sorry state of affairs in a later post.