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.

Plutophilia – a proposed diagnosis

Psycho-diagnostics are culture-bound. The “Bible” of psychodiagnosis in this country is the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM), and from time to time a committee of psychiatrists updates it. The current edition is DSM 5. In DSM 2, homosexuality was classified as a mental disorder, but this error was corrected in the next edition. The DSM 3 also eliminated the “neurotic disorders” listed in the prior editions. What used to be called Multiple Personality Disorder is now called Dissociative Identity Disorder. Some diagnoses have a limited lifespan.

Each diagnosis establishes multiple criteria (e.g.descriptions of symptoms), a certain number of which have to be met in order to establish the diagnosis as accurate. Psycho-diagnostics isn’t rocket science. It’s often imprecise, and relies more on theories than on verifiable data. Unlike most physical disorders, there are no biological markers to distinguish (for instance) Schizophrenia from Schizoaffective Disorder or Bipolar Disorder, manic. Much psychodiagnosis is educated guessing. The criteria for what’s considered psychopathology are values- and culture-bound, and sometimes arbitrary.

Mental illnesses exist in other cultures that aren’t found in the DSM.  Amok  is a mental disorder that occurs in Malaysia, Indonesia, and Polynesia, where people (mostly men) go berserk and assault anyone in their path. Koro is a persistent anxiety state that manifests in some men in Southeast Asia, based on their belief that their penis is shrinking, or retracting into the body, and that this can lead to death. Susto is a belief in “soul-loss” in some Hispanic cultures, which is believed to cause vulnerability to a variety of illnesses. A lot of people around the world believe in illnesses caused by voodoo/obeah/root magic hexes or spells, or the “evil eye.”

Having stated that psychodiagnosis is somewhat arbitrary and culture-bound, I’ll try to make the case for a new diagnosis that is bound, not to an ethnic or national culture, but to the multinational corporate culture. Only the very rich can develop this pathology. I believe  that there are cultural, economic, and political reasons why Plutophilia – excessive love of wealth –  isn’t a recognized  “paraphilia,” alongside necrophilia and  pedophilia. (Plutophobia – fear of wealth or money – is believed by some clinicians to be  a treatable psychopathology.) According to the Bible, it’s not money, but the love of money that’s the root of all evil.

Here are my suggested diagnostic criteria for a diagnosis of Plutophilia: (1) Obsession with the endless accumulation of wealth, far beyond what is needed or will be spent in a lifetime; and persistent or compulsive behaviors in the service of wealth accumulation. (2) Compulsive competition with other plutophiles in amassing the greater/greatest fortune. (3) Unconcern with the negative economic, social, and ecological consequences of their exploitation of workers and/or other resources, and of their obsessive profiteering. (4) Delusional belief in their (social Darwinistic) superiority as human beings, and in having “earned every dollar.” (5) Insatiability. No matter how much wealth is accumulated, it’s never enough. (6) The belief that their psychopathology  is a virtue. I’d say that meeting five of these six criteria would suffice to establish the diagnosis.

Plutophilia is responsible for the vast gap between the wealthiest few and the masses that live in, or on the edge of, poverty. It harms society as surely as an unending drug abuse epidemic. However, having the disorder can’t be the grounds for involuntary commitment and/or court-ordered treatment. Sadly, there is no known treatment or cure.

Models of Madness

In prior posts I’ve written about the pros and cons of the medical model (psychiatry) as the predominant model for the treatment of mental illness, and about what I call “the model muddle.” Models are ways of organizing and framing ideas in a way that serves as a guide. A good model is like a good map: it helps you to get where you want to go. The map is not the territory, but merely a helpful representation. No model is perfect and complete, or demonstrably superior to all other models, in all situations. Each one has its flaws and limitations.

Psychiatry is the medical model’s methodology for treating mental illnesses – primarily with medications. In a nutshell, the model starts with the identification of symptoms, which leads to an appropriate diagnosis, which in turn leads to an appropriate treatment.  The medical model is very good at what it’s good at, such as mending broken bones, doing surgery, and treating many physical ailments. But psychiatry is built more on theory than on scientific evidence.

One limitation of the medical model is that it’s mainly focused on what you do after you have symptoms, not so much on wellness and prevention. A distinct limitation of the medical model as regards mental disorders is that, unlike most common physical disorders, there are no identifiable biological markers to distinguish (for instance) what we call “schizophrenia” from “schizoaffective disorder” or “bipolar, manic.” Psychodiagnosis is not rocket science, because mental illness isn’t measurable in the way that many physical illnesses are (i.e. medical science can distinguish between asthma and pneumonia). At best it’s educated guesses, and many people with an extensive history of psychiatric treatment have been diagnosed with – and treated for – a variety of diagnoses.

Critics of psychiatry have argued that mental illness is a social construct and not a medical condition, and that psychiatry is a process of coercive social control. The negative side effects of some psychotropic medications and mood stabilizers outweigh the benefits for many patients. The term iatrogenic effects refers to treatments that do harm. Unfortunately, contemporary psychiatry is wedded to the pharmaceutical industry. That having been said, psychopharmacology has its place in the treatment of what we call mental illnesses. I believe that in some instances there’s no effective substitute for the right dose of the right medication at the right time. But I also believe that other interventions can mitigate the need for primary reliance on drugs as the default treatment for psychopathologies.

The biopsychosocial model takes into account such factors as physical health, heredity, stress, social stigma, social support system, mental habits, chemical dependency,  economic status, nutrition, and homelessness. We need to embrace a more holistic treatment model for what we call mental illness, and to provide a range of services that gives people who’ve been labeled as mentally ill more autonomy and more options for resolving problems related to their mental health. Unfortunately, the national mental health system is severely underfunded, and many people in need of help are underserved. This is a national disgrace.

The recovery model is an alternative to the medical model. A lot of mental health professionals initially scoffed at the idea of people “in recovery” from chronic psychiatric disorders. Recovery made sense as a helpful model for “recovering” substance abusers, but did it apply to the mentally ill? Many mental health professionals have come to recognize the merits of the recovery model, and there are now recovery centers/programs in some cities, that aren’t run on the medical model. Such programs don’t necessarily preclude psychiatric interventions, but also offer educational resources to empower patients, professional and peer support, and access to community resources, to reduce the stressors that exacerbate symptoms of mental illness.. The concept of recovery from mental illness doesn’t mean full and permanent remission of symptoms, but suggests that psychiatric treatment isn’t the only route to symptom remission and control of one’s life. To find out more about the recovery movement and alternatives to traditional psychiatric treatment, check out madinamerica.com.