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- BY
- Carole Willey
- Clifford Thurston
- Steven Pearce
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- The fundamental problem with the current mental health system is that
virtually no one recovers their health and very few are even making
progress toward recovery. [Reference King County RSN Recovery Model
report for 2001, 2002 and 2003 less than 1% recover their health. This
King County ordinance is or rather was (it was modified and no longer
tracks recovery of health) unique in the state of Washington. No other RSN,
nor the MHD tracks recovery of health]
- The public mental health system can be deemed to be a system of
maintaining individuals in their chronic mental illness. [Reference:
CCHR White Paper on CREATING CHRONIC ILLNESS, August 2004]
- This places a tremendous burden on the public mental health system to
meet existing demand, yet still be required to service anyone new to the
system who is Medicaid eligible.
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- There are several “reform” efforts underway. The Mental Health Task
Force spawned HB 1290 and SB 5763. We also now have the Mental Health
Transformation Grant with it’s subcommittees meeting around the state
currently.
- One of the issues being pushed are “Evidence Based Practices”.
- PACT appears to be being pushed, because it is being called an Evidence
Based Practice.
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- PACT stands for Program of Assertive Community Treatment. Notice the
word assertive. One of the main goals is ensuring treatment compliance.
- A PACT team can include: generalist staff trained as registered nurses,
clinical psychologists, case managers, substance abuse specialists,
occupational therapists, and vocational specialists, in addition to
part-time psychiatrists.
- P/ACT [PACT is known by other names, i.e. without the P as ACT) was
originally developed as an alternative to psychiatric hospitalization,
with the goal of allowing people to live independently in the community.
But, in reality, P/ACT has evolved into a coercive, lifelong and
non-client*-directed system with medication compliance as its most basic
tenet.
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- PACT does not solve the system-wide problem that people are not
recovering their health – their dependence is being maintained.
- According to the analysis of PACT in Clark County the mean GAF score is
54.3 which is in the “moderate” category. The range of this score
appears to be 41.2 to 67.4. This means individuals symptoms range from
serious to moderate – but nevertheless in the dependent to less
dependent category – not recovered.
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- For the years 2001 through 2003
King County RSN reported annually on outcomes based largely upon
GAF (Global Assessment of Functioning) scores. Clients were rated as:
- Recovered above 81
- Less Dependent 51 to 81 – mild
to moderate symptoms or
- Dependent less than 51 – serious symptoms
- GAF scores are part of Medicaid eligibility requirements in Washington
State. They are a widely accepted
measure of mental health. You can see this scale on the following pages.
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- Superior functioning in a wide range of activities, life’s problems
never seem to get out of hand, is sought out by others because of his or
her many positive qualities. No
symptoms.
- Absent or minimal symptoms (e.g., mild anxiety before an exam), good
functioning in all areas, interested and involved in a wide range of
activities, socially effective, generally satisfied with life, no more
than everyday problems or concerns (e.g., an occasional argument with
family members).
- If symptoms are present, they are transient and expectable reactions to
psychosocial stressors (e.g., difficulty concentrating after family
argument); no more than slight impairment in social, occupational, or
school functioning (e.g., temporarily falling behind in schoolwork).
- Some mild symptoms (e.g., depressed mood and mild insomnia) OR some
difficulty in social, occupational or school functioning (e.g.,
occasional truancy or theft within the household), but generally
functioning pretty well, has some meaningful interpersonal
relationships.
- Moderate symptoms (e.g., flat affect and circumstantial speech,
occasional panic attacks) OR moderate difficulty in social, occupational
or school functioning (e.g., few friends, conflicts with peers or
co-workers).
- Cont on next slide (slide 5)
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- Chapter 4 ● Transformation Goals, Objectives, Strategies and
Performance Measures
- B. IMPROVE CONSUMER SELF-SUFFICIENCY – PUBLIC VALUE
- Goal 2: Mental health care is consumer and caregiver driven, with
consumers, families, caregivers and advocates involved in individual
recovery and resiliency process.
- Develop and implement concepts and programs that prioritize goals and
outcomes that foster autonomy rather than maintenance and codependency.
- Strategic Plan 2006-2011 Mental
Health Division
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- When Dr. Daniel Fisher was a neurochemist working for the National
Institute of Mental Health in the late 1960s, he was convinced that the
key to mental illness was somewhere in the brain's messenger chemicals,
which he was studying. But that was before he was hospitalized with
schizophrenia and got a first-person perspective.
- "I found that thinking that everything was determined by chemistry
was very disempowering and very dehumanizing," he said. Fisher, 61,
who turned from neuroscience to psychiatry after his own battle with
mental illness, is now one of the leading proponents of a view that is
about as far from the lab bench as one can get. He believes that with
enough of a support system, people can recover fully from mental
illness, even from disorders such as schizophrenia that are widely
believed to be chronic, long-term illnesses for most people. Psychiatrist
To Discuss Recovery Published April 6, 2005 in the Hartford Courant
- By GARRET CONDON, Courant Staff Writer
- http://www.power2u.org/hartford_courant_5.6.05.htm
- National Empowerment Center, Inc.
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- An Empowerment Model of Recovery From Severe Mental Illness: An Expert
Interview With Daniel B. Fisher, MD, PhD
- Editor's Note: Randall White, MD, interviewed Daniel B. Fisher, MD,
PhD, Executive Director of the National Empowerment Center in Lawrence,
Massachusetts.
- Medscape: In your publication "Personal Assistance in Community
Existence: A Recovery Guide," you write that the recovery model
emphasizes that emotional distress is a temporary disruption in life.[1]
Can you elaborate?
- Dr. Fisher: …The most important finding in our research is that people
who have shown significant or complete recovery from severe mental
illness - - by that I mean schizophrenia, bipolar disorder, or
schizoaffective disorder -- have cited hope as an extraordinarily
important component in their recovery. Part of the recovery was being
around people who saw their condition as not permanent, a condition from
which they could take increasing control of their life and reestablish a
place in society.
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- Medscape: Your publications make reference to the difference in outcome
of schizophrenia in less developed societies compared with
industrialized societies. What does the research indicate?
- Dr. Fisher: The evidence is from 2 studies by the World Health
Organization (WHO), one in 1979 and the second in 1992, comparing the
recovery rate, mostly from schizophrenia, in developing countries with
the recovery rate in industrialized countries. In 1979, WHO had about
1800 cases validated by Western diagnostic criteria in developing
counties matched with controls from industrialized countries, and they
found that the recovery rate was roughly twice as high in the developing
countries compared with the industrialized.[4] They were so surprised by
this that they said, "Well, this must be a big mistake." So
they repeated the study in 1992, and they got the same results.[5]
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- ABSTRACT: The author reviews the clinical and special social
environmental data from the Soteria Project and its direct successors.
Two random assignment studies of the Soteria model and its modification
for long-term system clients reveal that roughly 85% to 90% of acute and
long-term clients deemed in need of acute hospitalization can be
returned to the community without use of conventional hospital
treatment. Soteria, designed as a drug free treatment environment, was
as successful as antipsychotic drug treatment in reducing psychotic
symptoms in 6 weeks. In its modified form, in facilities called Crossing
Place and McAuliffe House where so-called long term "frequent
flyers" were treated, alternative-treated subjects were found to be
as clinically improved as hospital-treated patients, at considerably
lower cost. Taken as a body of scientific evidence, it is clear that
alternatives to acute psychiatric hospitalization are as, or more,
effective than traditional hospital care in short-term reduction of
psychopathology and longer- social adjustment. Data from the original
drug-free, home-like, nonprofessionally staffed Soteria Project and its
Bern, Switzerland, replication indicate that persons without extensive
hospitalizations (<30 days) are especially responsive to the positive
therapeutic effects of the well-defined, replicable Soteria-type special
social environments. Reviews of other studies of diversion of persons
deemed in need of hospitalization to "alternative" programs
have consistently shown equivalent or better program clinical results,
at lower cost, from alternatives. Despite these clinical and cost data,
alternatives to psychiatric hospitalization have not been widely
implemented, indicative of a remarkable gap between available evidence
and clinical practice.
- THE JOURNAL OF NERVOUS AND MENTAL DISEASE 187:142-149, 1999
- Soteria House Model website
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- MISSION
- The mission of the Soteria-Alaska Pilot Program would be to effectively
and efficiently treat mentally ill individuals within the Alaska
community with a quality and cost effective program that demonstrates
the effectiveness of an alternative to acute hospitalization and which
allows them more choice and flexibility in the initial stages of their
illness than a traditional hospital program.
- VISION
- To effectively use a community and milieu recovery model as the basis of
a program to meet the needs of those Alaskan who would respond to such
an individualized approach to the treatment of their mental illness,
that if proven as a model will provide an additional choice/option for
effective treatment.
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- In 1987, a group of what I think of as refugees from the mental illness
system in Massachusetts founded the community and non-profit, Ionia, in
Kasilof, Alaska. They pooled their resources and created a lifestyle
that totally works for them.22 They now have over 40 people living
there, including many children. I don't think they have had a
psychiatric crisis in well over ten years, perhaps not since the
community was founded. They built their own log houses, eat a strict
macrobiotic diet, growing and gathering much of their own food, and meet
every morning for as long as it takes to work through any issues. A few
years ago, they needed some grant funding to expand their agricultural
operation and build a community building they call the "Longhouse."
The grant application brought what they were doing to the attention of
policy makers, and Ionia became an example of a group of people who,
after being pronounced hopelessly and permanently mentally ill, created
their own environment, and proved it is possible to recover from a
diagnosis of serious mental illness and thrive.
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- CHOICES, Inc., was formed to provide alternatives in the community to
the current medication dominated mental health system… CHOICES is what
is known as a Consumer Run program, where "consumer" means
someone who has been labeled with a serious mental illness and is a past
or present recipient of mental health services. More specifically, …
"at least 2/3rds of the members of the Board of Directors shall be
a past or present recipient of mental health services of such a nature
that inpatient care may have been necessary." The philosophy behind
CHOICES is reflected in both its name and the words which create the
acronym CHOICES -- Consumers Having Ownership In Creating Effective Services
-- which is people having options of their own creation and choosing.
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- Three basic components to the CHOICES:
- (1) Helping people (and parents of younger children) get what they want.
- (2) Providing the types of services Loren Mosher describes in Chapter 9
of his and Lorenzo Burti's excellent book, Community Mental Health: A
Practical Guide, which can be found at
http://choices-ak.org/grants/05TBGIOperating /Ch9.pdf.
- (3) Being a conduit for pass-through grants for consumer run programs
that have not obtained 501(c)(3) status.
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- Clubhouses believe that recovery from serious mental illness (SMI) must
involve the whole person in a vital and culturally sensitive community
within which members (adults with SMI) can receive the supports
necessary to lead productive and satisfying lives. Members are involved
in all operational aspects of the clubhouse, working side-by-side with
staff. Clubhouses offer a range of services including vocational
supports, community-based employment (Transitional, Supported, and
Independent Employment), education, housing, outreach, advocacy,
assistance with accessing health care, substance abuse services, as well
as social and recreational opportunities.
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- Today hundreds of millions of people worldwide are affected by mental
illness. People living with serious and persistent mental illness are
among the most severely stigmatized and marginalized groups in the
world. Human rights violations, poverty, a sense of shame, a lack of
education, and restricted opportunities to participate and contribute in
society are common.
- The International Center for Clubhouse Development (ICCD) was founded in
1994 as a response to this profound international crisis. Our work is to
create and nurture sustainable community based resource centers of
opportunity and hope for people living with mental illness. These
centers are modeled after the very successful Fountain House program in
New York City. Here we help people with mental illness participate in
society through employment, supported education, a circle of friends;
access to needed services (medical and social); and a place to belong.
The ICCD is a global network of such centers, called “Clubhouses.”
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- Recent SAMHSA (Substance Abuse and Mental Health Services
Administration) supported research has verified the efficacy of the
clubhouse model. In this study Clubhouse and PACT, Programs for
Assertive Community Treatment, programs were compared to each other.
Clubhouse participants were shown to have longer work duration and
higher earnings than those in PACT* programs. Clubhouse jobs were of
higher quality than those gotten by PACT model programs. And the cost
per person was demonstrated to be less in clubhouse than in PACT with as
good or better outcomes. Clubhouse not only addresses helping members
(clients) get jobs, but also addresses their social needs, a shortfall
in other less comprehensive model programs.
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- The clubhouse model has expanded over its nearly 60-year history in the
following ways:
- Today there are close to 400 clubhouses in 30 different countries around
the world serving over 55,000 people.
- In the United States there are 196 clubhouses in 32 states serving
approximately 37,500 men and women living with mental illness.
- 318 clubhouses belong to the International Center for Clubhouse
Development (ICCD) and 150 are ICCD Certified Clubhouses.
- 20 new clubhouses open each year with the assistance of International
Training Bases, located in New York, Massachusetts, South Carolina,
Missouri, Toronto, London, Sweden, South Korea, Finland and Australia.
- 120 new teams of clubhouse staff are trained each year.
- Recently, the United Nations gave the International Center for Clubhouse
Development “Special Consultative Status” with the United Nations
Economic and Social Committee (ECOSOC). ICCD is the only international
mental health organization with this status.
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- WE BELIEVE THAT THE 24-HOUR MOBILE CRISES intervention team should be
the center of every community mental health program. In most situations
it will function as the gatekeeper to the system. Systematic research on
the use of 24-hour mobile crises teams has shown that they reduce
hospitalization by at least 50%. The experience in South Verona (Italy).
- If a home intervention is thought to be necessary the team advises the
caller of the plan and asks for his or her reaction. If the plan is
acceptable, the caller is asked to assemble the parties relevant to the
problem and told that the team will arrive in about 15-20 minutes. If it
is a call from police on site, they are asked to stay also. A minimum of
two team members, preferably a male and a female, should respond… On
arrival the team evaluates the nature of the problem utilizing interview
techniques…. The actual intervention will use a variety of techniques ….
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- Alternatives to Hospitalization
- In a properly designed and functioning community mental health system
community residential treatment facilities should sere the vast majority
of disturbed and disturbing individuals in need of intensive
interpersonal care who cannot be adequately treated by in-home crises
intervention. Use of these small home-like facilities in conjunction
with 24-hour mobile crises intervention will dramatically reduce the
need for psychiatric beds in hospitals.
- [These are references taken from Chapter 9, A Community Services
Smorgasbord, from The book Community Mental Health by Mosher L.R. &
Burti L. (1992) Community Mental Health Chuo Hoki Suppen: Tokio
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- National Council on Disability, January 20, 2000
- Recommendations
- . . . NCD has developed 10 core recommendations in this report.
These policy recommendations should be viewed from the context of the
larger report, which follows. These deeply held core beliefs form,
however, a dynamic backdrop to highlight the human and civil rights of
people who have experienced the mental health system, people who should
be viewed as the true experts on their experiences, beliefs, and values,
which should be used as a guiding force for changing public policy
related to these issues in America.
- 1. Laws that allow the use of involuntary treatments such as forced
drugging and inpatient and outpatient commitment should be viewed as
inherently suspect, because they are incompatible with the principle of
self-determination. Public policy needs to move in the direction of a
totally voluntary community-based mental health system that safeguards
human dignity and respects individual autonomy.
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- 2. People labeled with psychiatric disabilities should have a major role
in the direction and control of programs and services designed for their
benefit. This central role must be played by people labeled with
psychiatric disabilities themselves, and should not be confused with the
roles that family members, professional advocates, and others often play
when "consumer" input is sought.
- 3. Mental health treatment should be about healing, not punishment.
Accordingly, the use of aversive treatments, including physical and
chemical restraints, seclusion, and similar techniques that restrict
freedom of movement, should be banned. Also, public policy should move
toward the elimination of electro-convulsive therapy and psycho surgery
as unproven and inherently inhumane procedures. Effective humane
alternatives to these techniques exist now and should be promoted.
- 4. Federal research and demonstration resources should place a higher
priority on the development of culturally appropriate alternatives to
the medical and biochemical approaches to treatment of people labeled
with psychiatric disabilities, including self-help, peer support, and
other consumer/survivor-driven alternatives to the traditional mental
health
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- Low expectations in the mental health system are both a cause and an
effect of decades of low results.
If less than 1% of clients are actually recovering from their
alleged ‘illnesses,’ then we must begin to examine both the theories
upon which their treatment is based and the actual effects of the
treatment. The treatment of
mental and emotional difficulties is based upon the theory that such
problems are the result of chemical imbalance in the brain. Hence psychiatric drug treatment forms
the core of all treatment programs.
But if psychotropic drugs really do correct the chemical
imbalance that is the source of the problem, why are so few recovering?
- The answer is twofold. First,
there is no proof that those who have been labeled mentally ill are
actually suffering from a chemical imbalance. An increasing number of psychiatrists
and neuroscientists are now arguing that the “chemical imbalance’’
theory is scientifically unsound.
Second, the cornerstone of psychiatry’s medical model of the
human condition has not been proven and the evidence for it is very
weak. In essence, clients of the
mental health system are receiving ‘treatment’ for a condition they do
not have, while the actual sources of their problems are largely
ignored.
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- There are two major consequences of this misguided approach. First, individuals spend years on
drugs that actually produce chemical imbalances in the brain. These drugs weaken and damage many of
the body’s vital organs, resulting in deteriorating physical
health. The drugs also have an
enormous psychological impact on the individual, commonly producing the
depressive or psychotic symptoms for which they are prescribed. The
result is that the drugs lead the individual away from recovery and
toward chronic illness.
- The second consequence is the actual source of the problem is left
untreated. That source is
frequently a real physical illness that has not been discovered and is
either directly producing the mental and emotional effects or
exacerbating them. Mental &
emotional effects can also be produced by numerous other physiological
conditions, including reactions to medications, nutritional
deficiencies, hormonal imbalances, and toxic and allergic
reactions. A simple lack of
exercise can play a significant role.
In addition, there are numerous social and psychological factors
that play an obvious role in our mental and emotional well being.
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- "As a practicing psychiatrist and neurologist, I've successfully
diagnosed and treated hundreds of patients whose emotional and
behavioral symptoms were caused by tumors, infections, toxins,
medication errors, genetic diseases, and other physical problems. Most
of them came to me after being tagged with psychiatric labels - manic
depression, anxiety disorder, attention deficit disorder – and being
given powerful mind-altering drugs or referral for psychotherapy. By the
time they called my office, many were desperate, some were suicidal, and
few had been significantly helped."
- Finding the Medical Causes of Severe Mental Symptoms: The Extraordinary
Walker Exam by Dan Stradford Founder, Safe Harbor Project
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- For several reasons, mental health professionals working within a mental
health system have a professional and a legal obligation to recognize
the presence of physical disease in their patients. First, physical
diseases may cause a patient's mental disorder. Second, physical disease
may worsen a mental disorder, either by affecting brain function or by
giving rise to a psychopathologic reaction. Third, mentally ill patients
are often unable or unwilling to seek medical care and may harbor a
great deal of undiscovered physical disease. Finally, a patient's visit
to a mental health program creates an opportunity to screen for physical
disease in a symptomatic population. The yield of disease from such
screening is usually higher than the yield in an asymptomatic
population. By Lorrin M. Koran, M.D., Department of Psychiatry and
Behavioral Sciences, Stanford University Medical Center Stanford,
California 1991
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- As PACT is not a recovery program and does not represent CHOICES, PACT
in any form should not be funded and if passed by the legislature should
be vetoed.
- This presentation was created by
- Carole Willey
- Clifford Thurston and
- Steven Pearce
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Notes
