Human Rights and Managed Care: Part 1

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Preface: Before I went to the American Psychiatric Association, many on this webzine expressed interest in my presentation to come on “Human Rights and Managed Care”. Given that interest, and how it may relate to some of our blog discussions, I thought I would post it for my blog. In a way, it is like Laura did in posting her most moving speech from the APA protest; I wish I could have been there at the time, as I would have liked to be as supportive as possible. Maybe next time. Of course, the content of my talk, put together well before I became involved with Mad in America, is much different. I also do not think anybody connected to this site attended our Symposium on Tuesday. By the way, I was also part of the presentation on Monday of a Humanitarian Award to Robert Jay Lifton, sponsored by the American Association for Social Psychiatry (for which I was a Past President). The AASP has long championed addressing the social issues involved in mental health and mental healthcare. Robert Jay Lifton is the award-winning writer who wrote about thought control, Nazi doctors, and led protests against the Viet Nam War. His recent memoir, Witness to an Extreme Century, is superb in my opinion and relates to the concerns on this site.

I’ll need to post my speech in several parts because it is way too long for just one. I’ll do this over the next week or so to keep the connections apparent and allow for discussion along the way. No references are provided, also for space concerns. And, of course, a speech usually doesn’t work as well when it is written out, so my apologies in advance for the writing. However, in terms of being open, I wanted to relay as close as possible what I said.

For those who are not familiar with what “managed care” refers to, it is the dominant way that healthcare and mental healthcare has been provided in the USA (the only country to do so) over the last 20 years. If any of you have gone for healthcare during this time, what you were able to receive likely was greatly influenced by a managed care company, which is in turn paid by the government or businesses. This system of review and authorization has had a major impact on psychiatrists emphasizing medications and spending less time with patients, as well as any clinician not being able to provide a lot of psychotherapy or alternative services (if they want to be paid by the insurance coverage). These for-profit managed care companies are very large. For example, United Healthcare covers over 80 million people in the USA.

This insurance mechanism will increase if President Obama’s healthcare reform continues to emerge, and not struck down by the Supreme Court. If we want healthcare and mental healthcare that is provided under private insurance, Medicare, or Medicaid to improve, this part of the system will need to be addressed. I think relating it to human rights is one way to do so.

Speech

Let us start off with a straw poll and vote:
1. Raise your hand if you think that managed care hinders human rights.

2. Raise your hand if you think that managed care benefits human rights.

3. Raise your hand if you think it does both.

4. Raise your hand if you think it does neither.

(If we get enough answers on this blog, we can tally them and compare to what I got at the meeting; my answer will be apparent as we go along).

There is a handout available that copies the 1948 “Universal Declaration of Human Rights”. What I want you to quickly see, if you already have not, is the introduction, for it gives the case of why these rights are important to be known well by us, our patients, and the public. Here are some excerpts from this introduction.

“All human beings are born with equal and inalienable rights and fundamental freedoms. . . In the Universal Declaration of Human Rights, the United Nations has stated in clear and simple terms the rights which belong equally to every person. These rights belong to you. They are your rights. Familiarize yourself with them. Help to promote and defend them for yourself as well as for your fellow human beings.”

(To be continued in Part 2)

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Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.

47 COMMENTS

  1. Thanks, Mary, for conveying your interest. Hope you find the rest of some worth.

    For “anonymous”, I’m glad you won’t say anything about me,not because I won’t like it or that it would not be civil, but do hope you might consider saying something about the topic, which is much bigger and important than I am or ever will be.

  2. Steve,
    I was excited to see this topic front and center when I posted my essay today. I hope to hear more about your experiences with “managed care” and the effects you’ve seen it have on both psychiatry and all of medicine.

    I had no idea that we are the only ones in the world using this model for a health care delivery system. It goes hand-in-hand with us being the only country that allows direct to public marketing of drugs. The “rise” of “managed care” is temporally related to the “rise” of pharmaceutical products and the loss of other medical professional skills.

    I remember being told by a representative of one new “provider panels” back in the early 90’s that I’d “better get on the bus” or I’d “be left behind”. They planned to tie it all up and control the “market”. And they’ve succeeded.

    I’m looking forward to the rest of your talk.
    Alice

  3. Dr. Moffic,

    Many of us have grown tired of the finger-pointing game being played by psychiatrists.

    Fingers of blame for a failed paradigm of care, that you and many others have been part of for quite some time.

    The three areas that are common are:

    1) Pharma companies
    2) Managed care
    3) Anti-psychiatry

    Excuses.

    We’re tired of the exuses.
    And we’re tired of the finger-pointing

    Let’s stop talking about “managed care”…
    At least long enough to talk about real reform.

    In other words, before we asks “Who’s gonna pay for this?
    We need to ask, “What are we paying for?”

    And in the case of bio-psychiatry, we have paid.
    And we have paid dearly.
    Each of us.
    All of us in this country.

    Be specific.
    What ideas for real reform do you have?
    How do you and your colleagues plan on implementing those reforms?

    Let us know.
    We’re anxios to hear what it is you have to say.

    But “managed care” is not the issue.
    “Real Care” is the primarly issue.
    Who pays for that care (what system we use) is important, but secondary… IMO, a distraction of sorts.

    Many of us on this site were born at night.
    But none of us were born last night.

    Duane

    • I hope my commment meets the guidelines.
      I’m doing my best not to be disrespectful.

      I’m challenging you, Dr. Moffic.

      We have some well-read people on this blog… Some very bright, insightful people who have done a lot of research. And I’m asking that you treat us with the same respect you are asking of us…

      And so, again:

      We know where your profession has been.
      Where do you plan to go (from this point-forward).

      We want to hear what you have to say.
      We want to know if there is any hope for the future within the field, or whether we would all be best to make our clean-break with the few psyhchiatrists who are real reformers.

      And, very few there are. Some listed here (scroll down the page)… A few are not listed, but there are not hundreds missing –

      http://discoverandrecover.wordpress.com/warning

      Duane

      Duane

      • Keep in mind, there are 50,000 psychiatrists in this country… 50,000

        How many have stuck their professional necks on the line, to do the right thing… to present the facts?

        50?
        Maybe.

        That’s 1/10 of one percent.

        Surely, now that the public is on to the scam, a few of you will step up to the plate and do the right thing… Come clean.

        Surely, psychiatry can bring the number up to one percent… 100 real reformers?

        If not, I guess the revolutionary change takes place with the fifty we’ve got.

        Duane

  4. Let me guess: The doctors thought managed care hindered human rights, specifically theirs.

    I fear this multi-part contribution is going to be about patients not having access to enough psychiatric care, when most of the patients participating on this site think of themselves as survivors of excesses in diagnosis and drugging.

    I always say to patients: “Managed care means YOU manage THEM” — meaning the doctors and insurance companies.

  5. Steven,

    I also read your Psychiatric Times blog and I would urge you to post the same ideas on Mad in America that you do for the Psychiatric Times. As you know, only “healthcare professionals” may comment on Psychiatric Times articles so people like myself cannot respond.

    To any readers who are not familiar with Steven Moffic’s writings for the Psychiatric Times I strongly encourage you to check them out. Do not be confused by the fact that he uses “H. Steven Moffic” in that context. His most recent piece is called “Is it time for reinstitutionalization?” and opens with Steven musing about extending the outpatient commitment order of one of his patients and Steven’s concern regarding the patient’s medication that “without it he’d surely relapse into psychosis and possible dangerousness.”

    Another piece by Steven for the Psychiatric Times which deserves attention is “Occupy Medicine.” At first the title made me hopeful but I was quickly disappointed. Steven makes the case that psychiatrists are in the 99% of medicine and claims that “plumbers make more per hour.” He argues that psychiatrists should take back their “product” and laments that other types of providers are encroaching on psychiatric territory.

    Steven finishes by noting “Thankfully, the anti-psychiatry movement has died down. In an unexpected way, there’s more of a pro-psychiatry movement becoming embedded in our systems. These are our patient consumers and peer specialists.”

    I don’t know how to post links on the device I’m using. Can someone who is able please link to these two pieces? Thank you!

      • Many of us have grown quite tired of the ‘anti-psychiatry’ label.

        I know I have.

        I am NOT best defined by what I’m against, but what I’m for.

        And like any other human being, I get to make those decisions.

        I consider myself:

        Pro-freedom
        Pro-recovey
        Pro-wellness

        The ‘anti-psychiatry’ label is a quick way to dismiss, to disenfranchise, to negate.

        And it is all-to-often followed by ‘Scientologist’.

        For the record, I’m a practicing Roman Catholic.
        I have no bone to pick with the Church of Scientololgy… I know nothing about their beliefs, nor do I care to know.

        I thought we lived in a free country.
        A pluralistic society.
        On that is supposed to be at best inclusive, and at least, tolerant.

        Enough of the anti-psychiatry label.

        Again, Dr. Moffic –

        1) What reforms does the APA have to offer?
        2) What steps are you taking to enact those reforms?

        You wanted a platform.
        You have one.

        We’re listening.
        But so far, all I hear are crickets…
        Lots and lots of crickets…

        Duane

        • Dr. Moffic,

          At the top of the MiA site is a tool bar.
          In the middle is a section ‘Source Documents’

          If you spend some time on these, you will see the injury that has been caused by psychiatric drugs – both ‘Anatomy of an Epidemic’ and ‘Mad in America’ sections.

          Many of us have read the scientific data, most of us have read the books as well. Along with many other sources of literature.

          And there are many who have experienced the injury described in this research first-hand, and/or had a family member who was injured.

          Some of us have been able to forgive.
          Others have not.

          Some are ready for reconciliation to take place. But reconciliation will mean that those of you in psychiatry who tell us you are reformers begin to act like reformers.

          Namely, that you stop the “business-as-usual” and begin to tell us of your reforms, and more importantly, that we begin to see those thigns take place.

          Your first post was about “Why we need psychiatrists” and you were blasted.

          Many of us wanted to give you a second (and third chance)… And many of us have.

          I’m frankly left un-impressed.

          You appear to be someone who is trying to save his own profession, but who has yet given any of us a reason to believe in reformation.

          I’m not even sure it meets the criteria of “all talk, no walk”.

          In short, what is it you want to say on this site?

          Duane

          • I think we need a Truth and Reconciliation Commission for psychiatry akin to what took place in post-apartheid South Africa. True mutual reconciliation requires clear admission of wrongdoing by those who have done harm. Not “I’m sorry you were offended” or “I’m sorry but it wasn’t my fault” but rather “I’m sorry I was wrong.”

            Without this step indivuals who have been harmed may find the grace to forgive but true mutual reconciliation has not place. It is often tempting for people who have harmed others to skip the hard work of justice and accountability and go straight to the warm fuzziness of reconciliation but I suggest that looking at other justice movements throughout history shows this is not the way to real peace.

      • His Psychiatric Times articles are outrageous! “Then how about the time when I sampled Thorazine to see how it made patients feel? Not a pleasant experience, I must tell you. There’s easier ways to learn empathy. I curtailed my self-experimentation after this. Yet, I think this experience may have turned out to be beneficial in other ways. It may be one of the reasons that I’ve always refrained from treating myself with any sort of medication, nor any family members, staff…” It looks like MIA won’t let me post the links…

        • If the links can’t be posted I hope everyone who reads Steven’s contributions here at MIA also checks out his Psychiatric Times articles.

          As someone who was duped into psychiatric treatment and seriously harmed as a result, transparency is very important to me.

          Moffic’s MIA blurb says he is known as “da man in psychiatric ethics.” If this is true the crisis in psychiatric ethics is worse than I thought.

        • Pychiatrist, Peter Breggin, M.D. points out in his work… the drugs have have the “same effect” on individuals who are viewed as healthy and those who are diagnosed as “mentally ill”. –

          http://www.breggin.com

          Maybe if more psychiatrists took a dose (several doses) of their own medicine, they would begin to see that what they provide is not “treatment”, but “mis-treatment”!

          Duane

  6. http://www.psychiatrictimes.com/blog/moffic
    Reinstitutionalization:
    http://www.psychiatrictimes.com/blog/moffic/content/article/10168/2066125
    Occupy:
    http://www.psychiatrictimes.com/blog/moffic/content/article/10168/2016343

    Most recent article:
    http://www.psychiatrictimes.com/blog/moffic/content/article/10168/2062591

    “Then how about the time when I sampled Thorazine to see how it made patients feel? Not a pleasant experience, I must tell you. There’s easier ways to learn empathy. I curtailed my self-experimentation after this. Yet, I think this experience may have turned out to be beneficial in other ways. It may be one of the reasons that I’ve always refrained from treating myself with any sort of medication, nor any family members, staff…”

    How can someone be so horrible?

    You will have to go through a lengthy registration process to get these articles, but I swear to god I did not make that up. He really wrote that! Recently!

  7. I’d like to know one thing: Why is Moffic given space on this website? He obviously is not concerned with the issues brought forth by madinamerica.com. He is one who believes that he should be able to commit someone for not wanting to take the drugs he so blithely prescribes, as clearly demonstrated in his recent piece for Psychiatric Times, “Is It Time for Reinstitutionalization?”, where he suggests that one patient’s insanity is demonstrated by his belief that the drug he’s prescribed deserves a zero on a scale of 0-10.

    Why is Moffic given space on Mad in America? He’s the antithesis of what this site is about. He’s what this site is against.

  8. Let me try to catch up on the comments while I am in the midst of my work at prison, where more than half of the inmates I saw today are off medications, for which I have worked with them to achieve.

    Those who are searching for my other blogs should know I actually do three regular ones:
    -this one, for which Mr. Whitaker asked me to do
    -Psychiatric Times
    -Behavioral Healthcare (available without needing to be a professional to view)

    If you want to comment on my Psychiatric Times blogs, or share them, please include all for a real picture.

    What I write for each varies as to the audience. I have never tried to hide anything. I’m also not trying to deflect any blame for psychiatrists, rather to share what I know that influences what happens in mental health care. I use my name, or all of my names (and I thought this group might like to use the more informal Steve or Hey-Hey). I hope to write something of value for each: here you know who you are; for psychiatric times, there are mainly psychiatrists and psychologists, and I have been trying slow but sure to change their opinions (and all should know my post on re-institutionalization was basically to criticise psychiatric hospitalizations that are too short to do anything useful for those patients who desire it; managed care will not authorize enough time and hence the connection to that process again); behavioral healthcare is for administrators. This is why I don’t try to post the same things for each audience. What would be great is that all three sites might end up with some agreement. However, the continuing criticism of virtually all psychiatrists will definitely not help make this happen. Even those psychiatrists who want real reform are likely to be turned away by this site. If you want us to reform, please consider being kinder, gentler, and more compassionate, the same you want from us psychiatrists.

    As to what I have been recommending for a long time, it is a Canadian style single payor system that will cover all, without for-profit managed care, and that will include prevention and alternative treatments. Oversite should be for a group having as little conflict of interests as possible, representing payors, clinicians, patients, and the public.

    • I’m also in favor of single payer in the US, aside from any influence it might have on psychiatric care, which is an Augean mess (see http://1boringoldman.com/index.php/2012/04/04/oh-hercules/ ).

      Steve, my intuition is you’re still trying to get a sense of the audience here. Bob Whitaker’s work brings to the fore the issue of iatrogenic damage in psychiatry. Many of the people frequenting this site are psychiatric survivors. (Others are mental health providers who are sympathetic to psychiatric survivors, or against pharmapsychiatry.)

      We’ve witnessed the iatrogenic damage first-hand, and we know it comes from doctors. There are people here who have been damaged by drugs, by ECT, and by involuntary treatment.

      All of those are hot-button issues for your audience on MIA.

      Now, there may be societal pressures on doctors, and for sure pharma has played psychiatry for fools. We know that inside and out, as well as we know our own medical histories. We don’t need to review it.

      The major issue I see is: How can we get doctors to stop injuring us? I’ve hoped in any dialog with physicians is that they would see our need and help us with this. I’m going out on a limb speaking for others, but that’s the coalition I believe we’re looking for here.

  9. Steve,

    I share your hope that people who read the comments section here will read your full Psychiatric Times blog pieces for a more complete understanding of your views. I think they speak for themselves. That is why I asked for someone to post the links.

    Because many people are not registered for the Psychiatric Times, and because only “healthcare professionals” may comment on that site, I suggest that you post your piece “Occupy Medicine: Reclaiming Our Lost Leadership” here on this site. If you stand by everything you write this should be no problem. In the meantime I stand by my characterization of this article and the representative quotes I posted above.

    BTW, for those who are frustrated by Steve’s failure to respond to the challenges about specific reforms in psychiatry in this thread, he does get specific in the Occupy Medicine piece, advocating, among other things, that psychiatrists need to retake their product of diagnosis and make the DSM-5 truly their own.

    Steve, you suggest that we try to be more “kind, gentle, and compassionate” if we want psychiatrists to reform. I suggest that there is nothing unkind or uncompassionate about pointing out inconsistencies or speaking strongly against injustice. On the contrary, using strong, civil language to call attention to psychiatric oppression is an expression of compassion and an act of solidarity with those who have been harmed and those who still suffer. The situation of your patient under the outpatient commitment and your evaluation of his situation come to mind. (Readers interested in this case and Steve’s take on it are encouraged to read his Psychiatric Times piece on reinstitutionalization.)

  10. I suppose I can be accused of being oversensitive, but what I feel is that many of the comments directed at me personally, rather than the issues, are like getting sniper attacks of words. Words do hurt. I know, not anything like medication side effects and withdrawals, etc. but they still hurt.

    I’m sorry I can’t send all the 30-40 blogs from Psychiatric Times here. One that I will mention, and by far the most popular, is a recent one on therapeutic dogs. Why don’t you link to that one, Sonia? I’d be curious about objections to that one. Selective selection of articles and quotes to confirm a point is really inaccurate, and as I said, I write different articles for different audiences, just as I would try to respond differently to different patients (though not force anyone to read anything I wrote or take any advice I give).

    Finally, a reminder that all the 20-30 blogs I have done for Behavioral Healthcare is open to anyone.

    • Steve,

      I am not asking that you post all your blogs from PT, just the Occupy Medicine one. I am not linking to your piece on dogs because I am not worried that your views on dogs are hurting people. I am worried that the positions you advocate in the Occupy Medicine do hurt people and will hurt people more if you achieve the changes you call for in this piece. I am not attacking you as a person, I am saying that your ideas about change in mental health are misguided. Specifically, I question your belief that psychiatrist should work to reclaim areas that have been taken over by other providers. You state: “other medical and mental health professionals have taken over our business to great extent.” You also say “Where we’ve really given up our product is diagnosis. Though the APA has put out the official diagnostic manuals in the U.S. for decades it for decades it opened up it’s use to any clinician who claimed enough expertise and knowledge. The APA makes a lot of money selling these manuals to other clinicians, who far outnumber psychiatrists, but what does this due to our role and status?”

      I object to these ideas, again not to you as a human being but to these ideas, because I think that the type of movement you are calling for here, one where psychiatrists reclaim their “products” and get to be the ones who control the DSM and resist the encroachment of other providers on their areas of expertise is not a good strategy for meaningful reform. To me, this is actually a regressive idea. You disagree, obviously, because you wrote the piece.

      If I am misquoting you or misrepresenting your ideas in this piece please say how specifically. I encourage everyone to read the full piece so they can judge for themselves if you are being quoted out of context.

    • Hello Dr. Moffic – I posted some rude things here, and I’m sorry. Thank you for explaining that Mr. Whitaker asked you to blog here. I feel like a dope for not realizing the obvious. Please note that the very first link I posted was a link to a list of all your blog postings on PT. It wasn’t my intent to quote you out of context, it is, in fact, your context I find extremely offensive. You do seem to either be misrepresenting yourself either here, or on PT.

    • Steve, Web debates are often rough-and-tumble. It’s often hard to get a sense of a person from posts, and people push the envelope.

      You are starting to be a real person here, thank you for that.

      There’s also something about virtual relationships that’s vividly emotionally engaging, more so than real life even. People will stew over some phrase and come back with guns blazing.

      It’s the Web, Jake. On the other hand, each commenter is communicating his or her priorities and, in some cases, intelligent arguments.

  11. I can’t keep repeating what I advocate for when certain of my ideas and blogs are taken out of context to conform to someone else’s points of view. I personally believe these issues and concerns are very complex and can’t be addressed, nor things improve, with brief statements. I also think this site needs to feel safer psychologically for people, patients, and psychiatrists with other points of view. That is not the case right now, and why what is posted is often repetitive.

    Sorry for the misspelling. Maybe I relied too much on spellcheck. Or, it is my age. I used to be a champion speller at one time, for what that is now worth.

    • In my opinion, that snipe at your spelling was out of bounds.

      You might confer with Kermit, I believe bloggers can delete “uncivil” comments on their blog posts.

      Envisioning your audience as patients injured by psychiatric treatment, what do you think the ethical issues are for them?

  12. Altostrata,

    I’m afraid I don’t agree that should be my audience. One of them, or the main one, but by no means the only one. As valuable as the opinions are of those who felt hurt by psychiatry, other perspectives need to be included if we are to make things better. I view my audience (and audiences if I include my other blog sites) as anyone who is interested in improving mental healthcare and mental health (wellness) in this country and the world.

    The ethical issues are formidable and complex and may take a blog to spell out. The ethical challenge for us psychiatrists, psychologists, social workers, etc. is to do the best we can with the knowledge available (which is why Mr. Whitakers book is so important) and do the least harm we can. I would cautiously venture that the ethical challenges for those who have been hurt is not to label all psychiatrists et al as bad and not to chase us away with vitriolic comments that at times to me has felt like “hate speech”. The ethical challenges for politicians and payors is to have a system adequately funded and that consumers are an important part of the decision-making process.

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