Mental Health Care in America: Why politicians and pundits are missing the point

Mental Health Care in America: Why politicians and pundits are missing the point

As a mental health practitioner, I am increasingly worried about the public perception that there is a connection between mental illness and violence. The truth is that persons with severe and persistent mental illness are no more likely to be violent than the average person. It just happens that when it does occur, the person’s mental health becomes a major fact in the headline. In response to the recent tragedy in California, the debate about violence and mental illness has intensified. Sadly, politicians and pundits have reduced a complex and nuanced issue to arguments about gun control and involuntary treatment of persons with severe and persistent mental illness. As a result, they miss the bigger picture; the mental health care system in the United States is broken and dysfunctional.

To illustrate, here are a few facts. The number of U.S. medical students choosing psychiatry is declining, and has been for some time. Here in North Conway, New Hampshire for example, we lack a single board-certified psychiatrist in private practice. In the United States, people are more than likely to have their psychiatric care managed by their primary care physician versus a specialist. Psychiatric bed availability is at an all-time low across the country. Individuals in need of inpatient care end up sitting in hospital emergency rooms for days waiting for a bed to become available. Insurance companies, meanwhile, continue to tighten benefits for inpatient and residential care, making it more difficult to meet eligibility criteria. The result is that inpatient units, under pressure to handle admissions in a timely manner, are having to discharge individuals as fast as possible, leading to premature discharges and outpatient treatment of persons who, in actuality, need a higher level of care. Stripped of adequate funding, outpatient community mental health clinics are unable to meet the demand, leading to long waits and increasingly stringent admission criteria. The clinicians in these clinics are overworked, vastly underpaid, and often fresh out of graduate school (I know, I was one of them back when I started out as a therapist). Even more disturbing is that treatment is increasingly secondary to ensuring compliance with a morass of federal and state regulations that have little, if any, connection to the health and wellness of those seeking treatment.

Here is one example of the dysfunctional federal regulations that exists in the mental health system. Medicare will only pay for therapy provided by a PhD psychologist, or a Masters level clinician if there is a supervising psychologist or medical physician in the building at the time of the appointment. This is despite the fact that the vast majority of therapists are Masters level counselors or social workers (deemed competent enough by private insurance and [with a caveat] federally-funded Medicaid to provide therapy without the PhD or MD requirement). In the rural community mental health clinic where I used to work, we did not have a full-time psychiatrist (increasingly common these days), meaning that we could only schedule people with Medicare for therapy on certain days and hours depending when the psychiatrist was in the building. If the psychiatrist had to leave for any reason then we had to cancel the therapy appointment or sign off on a waiver stating that it was medically necessary that the individual be seen despite the physician not being present (only valid in the case of an emergency). Not only does this regulation cause havoc for community mental health centers, it also means that people with Medicare cannot get treated by Masters level clinicians in private practice, unless there is a psychologist or psychiatrist in the practice (highly unlikely). No one has ever fully explained to me why the regulation exists, but as best I can understand, Medicare believes patients will get better care if treatment is administered by a psychologist or psychiatrist. Apparently Medicare also believes in osmosis because that is the only way the sheer presence of a psychologist or psychiatrist in a building could possibly impact therapy administered by a Masters level clinician. It is an absurd regulation, and yet, it is the reality. More disturbing, this type of regulation is commonplace in the mental health care system.

Another great example is the nonsense involving treatment plans. If you know of someone who works in community mental health, ask them to explain the issues surrounding compliance with treatment plans and signatures. To try and explain it would result in this post being much longer, and much more boring. What I can tell you from personal experience is that in the years I worked in community mental health I spent more time in clinical meetings discussing how to comply with the regulations such as treatment plan signatures (yes, you are reading that correctly. Meetings, plural, about signatures on a treatment plan), than I ever did discussing actual patient care. In conversations with others in the field of behavioral health, I have learned that my experience was not an isolated one, that this type of bureaucratic farce is systemic. Individuals with severe and persistent mental illness face enormous barriers to accessing quality care without adding the additional regulatory obfuscation that is unique to mental health care. If the same kind of dysfunction occurred for those seeking treatment for cancer, the public furor would be like nothing this country has ever seen. It simply would not be tolerated. Yet for those with severe and persistent mental illness, those who have no voice and are so vulnerable, quality care is secondary. This is not for the lack of effort on the part of providers. Clinicians who work in community mental health have a thankless job. They work incredibly hard to provide quality care to those most in need. But, they’re being asked to do their job blindfolded with their hands tied behind their backs.

Here is the ugly truth about mental illness in America. No one wants to admit that it exists. Sure, people love to talk about how hard we have worked to reduce the stigma. How good deinstitutionalization was for the dignity of persons with mental illness. How advances in medication and psychotherapy have led to the overall improvement in the lives of persons with severe and persistent mental illness. This is all true and very important. In many ways we have made great strides since deinstitutionalization. However, there is another, very ugly, very disturbing reality. Many people with severe and persistent mental illness are living on the very margins of society. They are homeless. Destitute. Rejected by society. The families who support them are being asked to shoulder more of the burden as access to basic care is increasingly restricted. Research funding is nowhere near the levels needed to meet the demands of the system. The prison system has become our de facto hospitals. People have to wait months to get into treatment. People have to resort to extreme measures to try and get help. Once they get into treatment, the treatment they receive is often barely adequate, administered by providers who are vastly overworked, underpaid, and burdened by regulations that have little if anything to do with enhancing the quality of care. As a society we have failed people with severe and persistent mental illness. The asylums of yesteryear still exist, they just aren’t hidden anymore inside a hospital building. Now they are hiding in plain sight.

A recent study came out that showed mental illness poses a greater mortality risk than smoking. Read that sentence again and let it sink in. Mental illness poses a greater mortality risk than smoking. The study showed that drug and alcohol abuse, for example, resulted in a reduced life expectancy between nine and twenty-four years; schizophrenia was 10-20 years. Smoking? It was 8-10 years. So despite the fact that persons with severe mental illness are no more likely to be violent than the average person, despite the fact that they are at a greater risk of dying early because of their illness, despite the fact that disability from mental illness results in one of the highest economic burdens on our society, despite the fact that persons with mental illness are enduring inhumane treatment that violates basic human rights, politicians and pundits want to argue about gun control and involuntary treatment.

I am not suggesting that either issue doesn’t belong in the discussion of mental health care; both are topics to consider. But here is the terrifying truth; the enhanced ability to force involuntary treatment and increased gun control legislation will not prevent future tragedies such as the one that occurred in California recently. The problem is far more systemic and in actuality has little to do with guns and violence. A violent crime occurs every 26 seconds in this country. Violent crime is not a mental health issue, it’s a societal issue. If politicians and policy-makers are serious about fixing the mental health care system in America, then they will stop partisan debate and spend some time listening to those of us in the field trying to provide treatment. They might not like what they hear, the changes needed will likely be financially costly, but we might actually be able to make positive changes to the way we deliver mental health care in this country. Those who suffer from severe mental illness deserve no less than our best effort. We cannot afford to continue failing them.

Reforming the Mental Healthcare System

Mental health has been in the news a lot recently, mostly for the wrong reasons. What is most disturbing is how some commentators are using the recent mass shootings as evidence to further stigmatize mental illness. While they talk about reforming a broken mental health care system, what they are actually promoting is institutionalization for individuals with severe and persistent mental illness. This is unacceptable and distracts policy-makers from the fundamental issue; our current mental health care system is broken, underfunded and often criminalizes mental illness.

Why do we allow society to blame those who suffer from these devastating illnesses when they are the victims? It is no secret that even the best evidence-based treatments are still not good enough. Yet, they represent the latest research and should be widely available to patients. Sadly this is not the case. Community mental health centers are underfunded and lack the resources to offer such treatments. Training is expensive and access is limited. Insurance companies frequently balk at paying for treatment that they argue is questionable from an efficacy standpoint. The complexity of the mental health system, divergent opinions about treatment, and limited access to care often leaves family and patients confused, frustrated and marginalized. It is not exaggerating when people say the mental health system is broken and in crisis.

So what can be done? To start, our leaders need to stop using these isolated incidents of violence as evidence to support changes in the mental health system. However well meaning, it sends the wrong message and ultimately does more harm that good. Secondly, the government needs to get out of the way and let those who understand mental health care take the lead. There is far too much bureaucracy and inefficiency in the system (the current government shutdown an outstanding example). We need congress to appropriate funding at a level that meets the current needs of the system, without any stipulations or interference from special interest groups. Appoint a director to oversee a complete reformation of the system who is given the authority to implement the necessary changes (versus the usual congressional route of asking for a report that never goes anywhere). The director should bring together the National Institute of Mental Health, the Veterans Administration, the Substance Abuse and Mental Health Services Administration, the National Alliance on Mental Illness, the Center for Medicare and Medicaid Services, as well as various research and provider stakeholders to develop a comprehensive plan that aligns research, training, advocacy and treatment objectives on a national level. Simplify the process for accessing care and reduce the administrative burdens associated with providing mental health care. Stop kowtowing to special interest groups and make mental health parity a reality. Create a national standard for reducing the criminalization of mental illness through the use of mental health courts and mandated treatment for those most at risk for violence. Ensure that there is adequate access to various levels of care nation-wide. Prioritize the implementation of electronic medical records that allow for seamless communication between providers. Provide funding for training providers that includes national standards for graduate programs and licensing. Revamp psychiatric training programs to ensure that psychiatrists are thoroughly trained in psychotherapy as well as psychopharmacology. Mandate that insurance companies reimburse for psychiatrists who provide psychotherapy. Provide incentives for the development of novel treatments, including medications.

This is a daunting list and incomplete. Critics may call such a proposal idealistic, too expensive and unworkable. However, what other options do we have? The patchwork approach has not proven effective and there is little evidence that leaving the process in the hands of a partisan congress will produce acceptable results. Overhauling the mental health care system can only be effective if there is a comprehensive, long-term vision that aligns research, treatment, training and advocacy objectives. It will be difficult and expensive, but those who suffer from severe and persistent mental illness deserve our best effort.

Suicide Prevention Month

September is suicide prevention month. Every year, more than 37,000 people die by suicide. NPR’s Science Friday did a wonderful piece on suicide titled “Diagnosing Destruction” which looked at the science and research behind suicide and suicide prevention. There are many excellent books to help us understand suicide and why people kill themselves; two that I have found particularly helpful are The Suicidal Mind by Edwin S. Shneidman, and Why People Die by Suicide by Thomas Joiner.

Statistically, we know that certain demographic groups are more at risk to die by suicide. These include being male, between the ages of 15-24 and over 65 and being diagnosed with a mental disorder. Despite these statistics, it is still impossible to predict if a person will make a suicide attempt. However, here are some warning signs that a person may be considering suicide.

  • Being depressed
  • Actively talking about death or desire to kill themselves
  • Researching ways to kill themselves
  • Purchasing a firearm
  • Expressing feelings of hopelessness or unbearable emotional/physical pain
  • Increased drug or alcohol use
  • Increased agitation or anxiety
  • Increased risk-taking behaviors
  • Extreme changes in mood
  • Rage or desire to seek revenge

Always take someone seriously if they say they are feeling suicidal. Even if someone has made suicidal statements in the past and never followed through, there is always the possibility that this time they will try to kill themselves.

If you or someone you know is thinking about suicide, here are some recommendations. Any person who is thinking about suicide should be evaluated by a qualified mental health or suicide prevention professional.

  • Contact your local or national crisis line or accompany the individual to your local emergency room.
  • Never leave someone alone who says they are seriously thinking about killing themselves.
  • Remove all firearms and ammunition from the home (locking them up is not considered sufficient).
  • Secure or remove any potential lethal medications or chemicals from the home.
  • Call 911 if the person is actively making an attempt to kill him or herself or is refusing to seek help.

Visit the Suicide Prevention Lifeline for more tips on how to help someone who is feeling suicidal. Military veterans also have the option of calling the Veteran’s Crisis Line.

The National Alliance on Mental Illness (NAMI) has developed a fantastic suicide prevention program called The Connect Project that aims to train community partners in how to prevent suicide and intervene when someone has died by suicide. In New Hampshire there are several grief support groups for family and friends who have lost a loved one to suicide. NAMI New Hampshire also provides resources for those who have survived a suicide attempt. Finally, NAMI New Hampshire hosts an excellent Suicide Prevention Conference each year.

Suicide is preventable. There is hope. Please make a difference by learning more about suicide prevention and educating others.

North Conway, NH Eating Disorder Support Group

Eating Disorders Support Group

An intimate group designed to receive support, learn coping skills, and find strategies to overcome an eating disorder.

Brought to you by local professionals, dedicated to helping people recover from their eating disorders. The group is open to individuals, 18 years or older, who are working towards recovery from their eating disorder.

Topics include:
• Learn new skills for overcoming disordered eating behaviors
• Find out how to start changing your mindset
• Discover new self-help strategies
• Enhance your support network

Location: Reporter Court, North Conway, NH

Cost: $40 for a 4-week series

Please call 603.319.4512 or email: for more information.

A bit about the clinicians…
• Nick Hudson-Swogger: Nick has an MA in Counseling from the University of New Hampshire and is currently pursuing a certificate in advance graduate studies from the Eating Disorder Institute at Plymouth State University. He is a trained DBT and FBT therapist and member of the Academy of Eating Disorders.
• Hope Patterson, Nutritionist & Wellness Coach: Hope is dedicated to eating disorder recovery by teaching her clients new eating strategies for their everyday life. Hope has a degree in dietetics from Simmons College and an M.Ed in Health Promotion from Plymouth State University, focusing on eating disorder recovery.
• Christine Wallace: Christine has a psychology degree from Salem State and an MS in mental health counseling from Nova South Eastern University. She also is a Ph.D-abd in metaphysical science. Christine currently practices privately in North Conway, NH, treating anxiety, depression, and addiction.

Embracing Difference

There’s a website I’d like to share today called Positive Exposure. The goal of the website is to show the unique beauty of people with various genetic conditions (albinism etc.) that are often portrayed in dehumanizing ways. It’s an amazing project, and it happened to come to my attention at the same time as I was reading two unsettling articles. The first was a report on CNN about the actress Mellissa McCarthy (of Bridesmaids among other films). Mellissa is a highly entertaining and talented actress who also happens to be plus-sized. Promotional material for her latest movie included a photograph of her that had been digitally altered to make her slimmer. While this practice is nothing new, it once again illustrates how hyper-focused our society has become on the thin ideal. While lifestyle choices are a contributing factor for obesity, there is also fact that weight and body type (ectomorph, mesomorph, endomorph) are genetically determined. What I found especially disturbing in the article was a quote from Ms. McCarthy where she stated that sometimes she wishes she would wake up and get people’s attention because she is emaciated. While disturbing, the comment does not shock or surprise me. Anyone who has worked with individuals who are obese or have an eating disorder other than anorexia has heard people refer to themselves as “failed anorexics.” Then you have Abercrombie & Fitch, a clothing company that goes out of it’s way to promote an ultra-slim body style by not making clothes in sizes that fit the average woman. Not only do their clothing sizes exclude most women, the CEO Michael Jeffries actually stated that their clothes are for “cool” kids (i.e. unnaturally thin women) and not overweight women. The venom against obese individuals even extends to college professors and Disney. I understand that the rising obesity rate in the US is concerning, and certainly a lot of it is due to lifestyle choices. But our current approach to tackling the problem is misguided. Shaming and ostracizing people because of the weight is not going to help them make lifestyle changes. Fad diets, diet pills and cosmetic surgery do not encourage people to make healthy choices. Ever-growing food portions at restaurants and the abundance of processed foods do not promote intuitive eating. Even the way exercise has become something you have to plan into your day, instead of being a natural part of one’s lifestyle (e.g. walking, hiking), is problematic. What we need is to do is rethink what it means to be healthy. The truth is that you can be healthy even if you are obese (the absurdity of the BMI is a whole subject itself). There are many people who eat healthy, exercise, and still are technically obese. Yet they are in good health. Instead of shaming them, we should be celebrating their accomplishments. Beauty is not determined by weight, and the promotion of the thin ideal in our society is backfiring. We not only have rising obesity rates, but rising rates of eating disorders, and they are occurring at younger and younger ages. Obese girls are often the subject of bullying, placing them risk for suicide and mental health problems such as depression. Being the victim of bullying and dieting are two known risk factors for developing an eating disorder. Disordered eating and body dissatisfaction are more and more common among women even if they do not have an eating disorder. It is not just women who are at risk. Males are also showing increasing rates of disordered eating and body dissatisfaction. The use of steroids, HGH and other methods of altering one’s body is becoming more common among young men in high school. When you consider all this, the reality is that we don’t have an obesity epidemic, we have a body dissatisfaction epidemic. It’s so engrained in our culture, we may not even realize we have an implicit bias against obese individuals (take the Project Implicit test for weight to see what I mean). Which brings me back to the website Positive Exposure. As a society, we like to talk about “diversity” and “acceptance”, yet often in our every-day lives we don’t live up to these aspirations. Take a moment and think about what it means to truly see beauty in every individual; to celebrate their uniqueness. Everyone is different; this is a good thing. The variety and diversity of life is what makes it so special. I challenge myself, as well as you, to be ever mindful of this truth and try and exemplify it each day.

I Am One of the 26 Percent

If you read the Concord Monitor, or are involved with NAMI NH, you probably have kept up on the series of articles over the past few years about the crisis within the NH Mental Health system. A number of these articles were written by a staff writer named Annemarie Timmins. She just published an article today called “I Am One of the 26 Percent” in which she has bravely discloses her own struggles with mental illness. It is a very powerful article, and a reminder that the majority of people who struggle with mental illness do not fit the stereotype many people imagine. I am including the links to all the articles from the Concord Monitor series – they are worth the read. One more reminder that as a society, we need to rethink our approach to mental health care.

A Four-Day Focus on the State Troubled Mental Health System
Mentally Ill Patients Face Spartan Conditions – Long Delays in NH
New Hampshires Mental Health System – From Leader to Failure
Community-Level Care is Key to Help Patients Return Home
Mental Health Court Gives Offenders Treatment – Not Time
In Crisis – Future Uncertain for Mental Health Care in NH
That’s Not the Kind of State We Are – Why NH Needs to Fix Mental Health Care Now

Eating Disorder News

Just a few eating disorder-related news items to pass along in this post. The first is that a parental education law was just passed in Virginia. If you haven’t heard about the controversy regarding the new Victoria Secret “Bright Young Things” product line that targets young teens, I recommend you read this and this. While eating disorders are certainly biologically based brain disorders, there is no doubt that cultural influences that perpetuate the thin ideal contribute to these illnesses. I hope that pressure can be put on Victoria Secret to end this product line. On a more positive note, there was a nice article on CNN recently about a woman who recovered from her eating disorder. While we still have a long way to go in developing effective treatments for eating disorders, one fact that research has shown is that if you intervene when an eating disorder first presents, and are able to treat it effectively, the risk of relapse decreases significantly. That is why programs such as the one being developed in Virginia are so important. The earlier we identify and treat these illnesses, the better chance they will not become chronic conditions. I hope that we see similar legislation in New Hampshire in the near future.