What's Next for Mindfreedom -and the American mental health care system? Making the system effective!
Comments for the 2005 Action Conference
Nathaniel S. Lehrman, M.D.
Mental hospital patient, 1963 - 4  (3 months)
Clinical Director, Kingsboro Psychiatric Center, Brooklyn NY, 1973 - 1978

The focus of this conference is the abusiveness of today's mental health care system.  In zeroing in on "human rights in mental health," and "how law can support human rights in the mental health system," it calls long-overdue public attention to the system's destruction of those rights.  

But mental patients need more than their "human rights." Their first need is for EFFECTIVE CARE.  While attorneys at law are needed to protect hospitalized mental patients and their rights, competent mental health professionals are the only ones who can meet their most important need: good treatment leading to full recovery.  The harm produced by care today is shown by the increase from 3.5 to 5.8 million, over the past fifteen years, in the number of Americans receiving social  security benefits for mental disability. This is a subject which Mindfreedom will have to address if it is to be more than a justifiably angry voice spitting into the wind.

Here I will first outline some of the characteristics of good care for the mentally disabled.  Then I will define some of today's ideological and organizational impediments to providing effective  care. I will end by pointing out how the drug companies are far from the only beneficiaries of our current poor care.   

These issues are scrutinized in my attached "If I Were Commissioner" paper - so titled because in every state, the person responsible for the organization and provision of mental health care is the state mental health Commissioner.  It is he or she, and those to whom he or she reports, rather than federal or local officials, who should be the primary targets of efforts to make care effective.

1. Good care for the mentally disabled
The heart of good care for the mentally disabled is the establishment and maintenance of trusting relationships with them by those caring for them - the professionals especially.  The importance of the therapist-client relationship cannot be overemphasized.   In medicine, the former deputy research director of the Rockefeller Foundation has shown that the doctor-patient relationship is responsible for approximately HALF of a physician's therapeutic impact in ANY medical situation.  In mental health, which lacks specific medical remedies such as penicillin, that impact is even greater.

Since this relationship is the mental client's major need, his care must be organized around it.   "Continuity of care" is the technical term for having the same competent professional caring for a patient from the latter's initial admission to hospital or other structured environment, thru his recovery in office or after-care clinic, to his final discharge as, hopefully, recovered.

Care continuity fosters the creation of trust between client and professional, thus allowing the care provided to be truly voluntary.  Continuity also allows the professional accountability which is currently destroyed when patients are transferred to other professionals and treatment teams as they move from one treatment setting to another.  

Professionals' motivation to help will increase significantly if they cannot transfer their failures away. Then they will be much more likely to try to understand the client as an individual  (rather than as merely a label), the circumstances leading to his needing mental health care, and what he himself must do to overcome them.  While the professional's seeking to understand his client as a person is therapeutic in itself - by helping to empower the client - it can also help correct today's gross overemphasis on medication.

2. Ideological and organizational impediments to good care
Hopelessness is the most important ideological impediment to recovery from disabling mental illness.  Its most important source is the biological psychiatry notion that mental illness is really "brain disease" ("chemical imbalance") and therefore essentially irreversible - altho supposedly ameliorated by brain-damaging chemicals. Unfortunate consequences of this primary reliance on drugs are clients' increasing reliance on street drugs when they feel uncomfortable and the fostering of  invol untary treatment (i.e against the clients' wishes) to overcome their objections to caretakers' reliance on medication.  

One important organizational impediment to good care is its fragmentation: the repeated transfer of clients from one treatment setting to another whenever their treatment locus changes. This repeated creation and destruction of trusted relationships leaves clients unwilling or unable to trust their caretakers - thus destroying a most important therapeutic tool.

The deprofesssionalization of mental health care is another obstacle to quality. Altho much information has been accumulated over the years on proper counseling of the mentally disabled, the current justified disgust with psychiatry and its practitioners for allowing drugs to replace therapuetic relationships as the core of treatment should not lead to the total discarding of professionalism. This would allow care to fall into untrained hands. Peer groups, while popular, are no substitute for professional skills.   And past victimizaton by psychiatric abuse is no substitute for good professional training.

The pairing of substance abuse and mental health treatment is another obstacle to good mental health care. Substance abuse treatment often requires a compulsional element, especially when illegal substances are involved.  Linking it with mental health care increases the compulsional element in the latter - to its detriment. The most striking example of this pairing has been the creation of the federal  Substance Abuse and Mental Health Administration (SAMHA); note that subtance abuse is listed first.  Similar pairings have occurred on state and local levels.  It is noteworthy that the major experience of Dr. Sally Satel, a most visible supporter of compulsion in mental health care, has been in substance abuse clinics.

3. Beneficiaries of poor care
The drug companies do not bear sole responsibility for today's poor care.  Governmental agencies are also responsible.  These include the National Institute of Mental Health and the Food and Drug Administration on the federal level.  Since  both are located in the Washington DC area, might they also deserve picketing by the MindFreedom conference?   

On the state and local levels, many public and private mental health agencies have become bureaucratic fiefdoms, more concerned with preserving baby-sitting empires than with helping clients recover.   One of the worst is the New  York State Office of Mental Health, with which I was long associated.  One manifestation of its harm to patients was its insistence four years ago on continuing to electro-shock Paul - Henri Thomas, despite his objections, into a permanently brain-damaged state. I was at one of his hearings, and was shocked at the damage which to me was quite evident.

I fear lest the MindFreedom conference be little more than another long, loud, and well-deserved attack on the current mental health system, but which presents no significantly useful ideas for correcting it.  While civil rights in mental health facilities are necessary, and long overdue for good treatment, they are by no means sufficient to provide that treatment. Rather than limiting themselves to objecting to today's horrors, those concerned with the mentally disabled should also be actively seeking to create an effective care system for them.

Attached:  "The Rational Organization of Care for Disabling Psychosis: 'If I Were Commissioner'"