Reflections on the State of Public Mental Health Treatment

As my year-long intenship is wrapping up at a public community mental health clinic, I thought it would be an appropriate time to offer some reflections about the quality of mental health care people are receiving in this country. Starting in two weeks I’ll be transitioning to begin a post-doc at a private psychiatric hospital. The transition will be quite an adjustment. Currently, the majority of the patients I am seeing are on Medicaid or Medicare. Many of them are also being treated by psychiatrists for “medication management” and some are also in a community psychiatric program where they are paired with a community support specialist who attempts to promote the patient’s adjustment to the community by providing resources. The critiques I will lay out on this post are not directed towards any of the social workers, psychologists or psychiatrists who valiantly provide mental health care to the severely “mentally ill” who are serviced in community mental health clinics (CMHCs). These workers are vastly underpaid and unappreciated. The pay that psychologists receive is a complete insult. Of course, the pay is dictated by Medicaid’s cheap reimbursement for psychotherapy and psychological testing. Many psychologists opt to go into private practice or enter private hospitals or clinics where they are more adequately compensated for their services. Along with the wonderful training I will be receiving during my post-doc, the benefits and pay certainly played a significant role in my reluctant decision to transition from a public to private setting.

First, psychotherapy is undervalued and disrespected. What I found most disappointing at my local CMHC was the push to make therapy “short-term,” offering 2-6 sessions for individuals. Any person who has taken an honest look at psychotherapy research knows that 12 sessions is the least amount of time that can be offered for treatments that have been “empirically-validated.” Second, those sorts of successful short-term therapies are primarily offered to neurotics who have mild depressive and anxiety symptoms. Individuals who are seen at CMHCs are amongst the most severely mentally ill and they often are diagnosed with multiple disorders including the following: personality disorders, major mood disorders (Major Depression or Bipolar Disorder), anxiety disorders (e.g. PTSD), schizophrenia, dissociative disorders and substance abuse. Given that many of these individuals carry multiple diagnoses none of them will be able to obtain a lasting benefit from short-term therapy due to the complexities of their struggles. There is also something cynical about reducing therapy to this “drive-by” intervention. Of course, it prevents the psychologists from conducting extensive clinical histories, which is easily the most important task for all psychotherapies. Furthermore, psychologists and counselors are so overbooked at CMHCs due to the high demand, forcing many of these patients to only be seen on a bi-weekly basis. Psychotherapy is most successfully conducted when not much time is allowed to pass between sessions, as it increases resistance and also transforms therapy sessions into updating the therapist about the past events of the previous weeks. Lastly, therapy is often reduced to being supportive rather than an in-depth exploration of the person’s history, conflicts, development, desires and struggles. Therapy is often reduced to providing the individual with “coping skills” to “manage” their “illness.” The message is clear: therapy is an adjunct to psychiatry, the true queen of mental health.

Second, while psychotherapy is disrespected, psychiatry is given undue respect. The amount of medications that many people are offered is unwise and sometimes harmful. The overmedication of the poor and severely mentally ill often prevents these individuals from working, engaging in romantic relationships (due to sexual dysfunction), maintaining good physical health (due to excessive weight-gain and the effects of some psych meds) and excelling in school (due to cognitive and emotional restriction). Of course, medications can be helpful for certain individuals and it can increase the individual’s social adjustment. However, the “medication-first-model” is simply unproductive. Disability rates continue to rise in this country and psychiatric disorders are a major contributing factor.

Furthermore, the overmedication of children (particularly traumatized children who are often placed in foster homes) has created significant problems. You cannot medicate someone out of trauma; you can only help dampen the affects and anxieties associated with the trauma. Fortunately, some actions have been recently taken, as evident by this announcement by Kathleen Sebelius, the Secretary of Health and Human Services. She announced that research on complex childhood trauma found that these children have been inappropriately treated by our current mental health care system. Around 90% of children placed in foster homes exhibit signs of complex trauma and they are often prescribed atypical antipsychotic medications (2nd generation) that do not help and might cause harm. Also, we know that children on Medicaid are five times more likely to be prescribed antipsychotics when compared to children on private insurance (so maybe one should be considering the option of switching health insurance). Thankfully, this report proposed re-directing resources to developing more successful psychosocial therapies and diverting funds away from medication.

Lastly, biological psychiatry might provide temporary relief to families and patients who do not want to be unduly burdened with guilt over being responsible for causing the patient’s mental illness. It can be comforting to know that your son or daughter or husband or wife has a genetic or neurochemical problem for which nobody (other than God) is responsible. However, psychiatric patients can pay a high price for this theory. While it offers relief it can also increase hopelessness and stigmatization, especially for individuals contending with some of the most severe mental disorders (e.g. schizophrenia). I am always amazed at how many of these individuals are never asked about their experiences of hearing voices or seeing visions or having strange thoughts. Often times, the individual’s experience and the way in which they interpret those experiences are secondary to the mere fact of having those experiences. The life history, losses, traumas and experiences are not considered, even though research shows that two-thirds of people begin hearing voices after suffering a loss or trauma or having experiences that remind them of previous losses or traumas. Ultimately, what makes therapy and mental health treatment work is the ability to foster the patient’s curiosity about themselves and their mind. If the mental health provider does not take an interest and genuine curiosity in the patient’s life and experiences of psychological struggles then the psychodynamic aspects that underlie the symptoms are lost as medications bury those processes with their powerful effects.