What We Are Talking About When We Talk About Community Mental Health

Sandra Steingard, MD
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This is the five year anniversary of this website and my blogging life. This experience has changed me in profound ways, and I am grateful for the platform. I have met people from all over the world. I have engaged with them in fruitful and sometimes challenging conversations. I have been invited to meet with and speak to many of them. I have been exposed to ideas and perspectives that were new to me. I have been invited to join and now chair the board of the Foundation for Excellence in Mental Health Care and I am active with Mad In America Continuing Education. I owe all of this to Robert Whitaker and MIA.

My stance towards my profession has evolved but remains decidedly critical. And while some ideas have crystallized for me (my best articulation of how I want to be as a psychiatrist is captured in my Slow Psychiatry blog), I struggle with whether I can do this work in an ethical way when there are forces and perspectives prominent in our culture that are antithetical to mine. Yet, I have kept my day job as a psychiatrist in a community mental health center in Vermont. I still work day to day with individuals and their families who come to our center seeking help. When I stop working, I am likely to stop blogging; it seems important to remain connected to this work lest I tend to romanticize and forget just how challenging it can be.

It often feels as if we are under siege in community mental health. Social support services constitute a large share of the budget for any state in the US. I work in a progressive state but, even in Vermont, we are constantly under pressure to do more for less. Lawmakers – faced with mounting expectations to lower taxes — question if we are both necessary and effective. We are generally under the umbrella of the medical community in the sense that we are largely funded by a health insurance system (Medicaid) but we are a step-child; we bring in relatively little money compared to more procedure oriented specialties. And as I have learned from MIA, we often do not have partnership with the advocacy community who can view us as the enemy — for many reasons, but often the most critical one is that we enforce state policies on coercion.

The past five years have been simultaneously transformative not only personally but systemically in Vermont. In August, 2011, Hurricane Irene effectively shuttered our state hospital overnight. A debate that had been waged for a decade over the future of the hospital was finally forced to a resolution. The result was construction of a 25 bed hospital built to replace the old 50 bed facility. More beds were added at community hospitals and several non-hospital programs were developed to help meet the needs of individuals who would have in the past spent time in hospital. There was an infusion of money into the community system and we were able to develop some innovative programs.

While this seemed like a win for those of us promoting more community-based services, we now have times when people are waiting in emergency rooms or jail for days for a hospital bed. In addition, when someone in the community has a crisis that brings public scrutiny, it is blamed on the reduction of hospital beds and a skepticism about the value of the work we do in the community. In an odd twist, the rate of forced hospitalization has risen. All of this has led to a call for more hospital beds. I do not pretend to understand the multiple forces at play that has led to a situation that I did not anticipate, but one thing I have learned is that it is very hard to change people’s minds about beliefs that are deeply entrenched. While I am not anti-hospitalization, I do not see it as the answer many of my colleagues perceive it to be. But they probably view me as the one with overly entrenched beliefs. One of them told me that I was too passionate to be able to critically analyze my ideas. For someone who values critical discourse, that was a deep cut.

I was asked to write something for a fundraiser for my agency. What follows is what I wrote to honor the many fine people who work day in and day out under the radar for modest salaries and limited appreciation from the community. It was a time when the press had highlighted stories of people who fall under our purview with partial information in a sensationalized way. It was hard to not feel defensive. This essay was written for an audience that I expected was more accepting of the conventional narrative than the MIA crowd. I wanted to share it here — I always find your response of great value — but thought it required some context.

* * * * *

The era when I was a young physician was one of great optimism for science and medicine. We were still riding on the advances made through the discovery of lifesaving antibiotics and the unraveling of our genetic code. We thought it was just a matter of time before most diseases would be conquered.

And that was the language, the language of war — conquering, vanquishing — that constituted our discourse. This discourse and the expectations that lay behind it entered the world of psychiatry with the notion that it was just a matter of time before we would find the genes that cause all of the problems our patients face, which in turn would lead to identification of the molecules — the drugs — that would erase their suffering.

My career began in the aura of this hope and optimism.

But there was a counter narrative, one that has deep roots in Vermont and was embedded in the growth of the community mental health centers during the 1980’s and 1990’s. It was the narrative of recovery. It was the narrative of social inclusion. It was the narrative of rights for people who had been marginalized and whose lives had been discounted. This narrative also told us that most people can recover.

We have since learned that there are things we, as healthcare and social support providers, families, and communities, can do to dampen the hope upon which that narrative is founded and things we can do to foster it. We know that offering hope, helping people find a path of meaning in their lives, and improving social connections, and community acceptance will help people to recover.

The dominant medical structures in our world are predicated on the first narrative, the narrative of the victory of medical science and the defeat of human misery. Community mental health programs in Vermont, while not ignoring the achievements of modern technology, are deeply imbued with the values of the second narrative, the narrative of recovery.

Something interesting has happened in recent years. These narratives have come together. The advances in science and technology have taught us that we need to think in a holistic way. We can’t conquer all infections with antibiotics because the bugs outsmart us. We are compelled to think about infections in the context of our environment. Studies of genes — especially in the area of mental health — have led to a deeper understanding of the complexities of how our genome makes us who we are, but for the most part not to cures. And the molecules — the drugs — we give people can be useful tools but they rarely cure.

As for the value of social connections? Finding meaning in life? We continue to learn about their power to heal.

Part of the work at my agency is to help people find their respective paths to recovery. We do this with hope and humility. Every day, we partner with people who make remarkable progress. Just as we have learned that we are not as successful at conquering disease as we had once hoped, we have also learned that the road to recovery can be a long, bumpy, and circuitous one. Social inclusion, while laudable, takes work. Some of our neighbors may cause discomfort and disruption.  Whose responsibility is it to support them through these difficult times? What are the limits of the capacity of our community to support them? When should we intervene and remove individuals who are disruptive from our communities for their safety or ours? These are complex and often ambiguous questions. Consensus can be hard to achieve. When these challenges erupt into public view, the answers may seem obvious to those who are not immersed in the myriad decisions that those involved in this work struggle with daily.

My colleagues and I grapple with these questions every day. We are in the community helping people live meaningful loves of independence, find jobs, succeed at school, and understand what drove them to use drugs or become entangled in the criminal justice system. We help them find safe places to live. We are in their schools, their homes, our courts, and the marketplace.

Are we perfect? No. My career has been one of repeated, almost-daily lessons in humility. But, we are always striving to improve. I continue to believe that we do remarkable work, much of which happens in the very private, quiet moments — the small steps toward creating lives of meaning that are deeply valuable, personal, and important but rarely the topic of the evening news.

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12 COMMENTS

  1. Sandra, If your primary goal is to wean as many people off of the toxic poisons your profession calls meds and to unlabel the humans and free them from the pseudo science you make a living from then you can pass this message to the true believers in psychiatry. Better than slow psychiatry is NO PSYCHIATRY . Educate yourself for real instead of trying to teach. Learn Traditional Naturopathy, Homeopathy, become real and ask those who have survived the electric gestapo chemical drug atrocity to teach you something so you don’t continue to wander around in the academic swirl of nonsense for profit and delusional self praise under a guise of humility.Sincerely , Fred

    • Thank-YOU!, Fred Abbe, for saying so eloquently what *I* also, think…. Sandra works in Vermont, which is very much like the small State to the East, New Hampshire, where I am now. Here in Keene, the local “CMHC” is “Monadnock Family (& Mental Health) Services. (They deliberately dropped the “& Mental Health” part of their name a few years ago, in order to more better FOOL the Public as to their true, evil mission.) One of my friends is one of MFS’s “drug zombies”. An MFS staff person *LIED* about my friend, which caused her to be incarcerated for 4 days in the holding cells of the local hospital ER, “Cheshire Medical Center/Dartmouth Hitchcock-Keene”. Sandra knows of it. After 4 days involuntary confinement, she was transported to the State mental hospital in handcuffs and shackles, in the back of a Sheriff’s cruiser. After 3 days in State, she was sent home in a TAXI CAB. While in the State, she was seen by a new, stranger-to-her, quack shrink psychiatrist for a few minutes. She continues to be grossly over-medicated by Court order, under the direction of MFS. She is a traumatized sexual and physical abuse victim. Overall, the local “CMHC” is doing FAR MORE HARM than good. THIS is the REALITY which Sandra suffers such extreme professional anosognosia about. I won’t hold my breath, but I’d LOVE to see Sandra’s response….
      And on Monday, Feb. 27, the local newspaper, the Keene Sentinel, had a front page story about the “crisis” in NH Hospitals, of holding cells and waiting rooms in ER’s being filled beyond capacity with persons waiting for beds in the State Loony Bin. The fabricated, manufactured “controversy” is over whether more funds should go towards “community treatment”, or building more “hospital beds”, to meet the (BOGUS) “need”….. This, while the State itself was found 2 years ago to be in substantial NON-compliance with a previous Federal Court order as regards treatment of the so-called “mentally ill”, which resulted from a Federal Lawsuit brought against the State. The situation is largely the same in Sandra’s State of Vermont. Isn’t it, Sandra? Comment?
      (c)2017, Tom Clancy, Jr., *NON-fiction
      AFFIDAVIT: I do hereby swear and affirm, under pains and penalties of perjury, that everything I’ve written here is true, complete, and accurate, to the best of my knowledge and disability.

  2. Thank you for this article. I also believe hope and humility are the key ingredients to providing support to people in extreme states. Passion and caring are important too, which made me very annoyed with the statement that professional said to you that you were “too passionate to be able to critically analyze [your] ideas”. This statement seems to me just another way to undermine a narrative different than the dominant narrative; even if it is phrased in a more ‘positive’ way ( probably because the person also likes and respects you). I personally have never seem any professional critically analyze their ideas more than you have over the course of your journey. I , for one, hope you keep blogging even after you stop working.

  3. Sandy,
    Well-written article; your heart and compassion comes through in this. These are some of the most important things to heal people, regardless of our orientation.

    I was just reading an online book you might like, that gave me some new insights into why the brain disease model did not pan out and lead to cures:

    http://loisholzman.org/2015/08/the-overweight-brain-chapter-6/

    It looks like the faulty unscientific assumptions made early on in the process of researching the diagnoses doomed the research effort.

    Regarding hospitalization as an “answer”, I find it puzzling when people say these things too. To me, the only “answer” found in confining someone for a few days or weeks is that they might be physically safe for at least that long (but maybe less safe after). From my experience, little therapeutic engagement occurs in hospital settings, although your hospital could be different. And there is no “disease” being medicated, just severe terror, confusion, rage, and despair being tranquilized to a temporarily tolerable level – a process which cannot address the developmental/identity issues and lack of social supports which often underlie the distress. And then the social factors and emotional issues causing problems are obscured by the imposition of the unsupported brain disease narrative, leaving the person and their network less able to innovate, think for themselves, and have hope. This is just speaking generally about American psychiatric hospitals by the way, not about you in particular.

    You might also share with your cohorts the apparent results of gradually increasing medicalization and drugging of severe distress (“schizophrenia”) over the last few decades: gradually decreasing rates of functional recovery, as discussed in Jaaskelainen’s meta-analysis where it was admitted “We are not getting better at getting our patients better” –

    https://www.yellowbrickprogram.com/ArticlePDF/Jaaskelainen-2013-A-systematic-review-Bull.pdf

    The bad news, from the biological/genetic perspective, is that no genetic breakthroughs, nor any new breakthrough drugs, are likely coming to change this dismal picture.

  4. NO HOPE IN MENTAL HEALTH SEGREGATION COMMUNITY,sounds like a ghetto for crazies,to me!Indeed I am tired to live in world where normals are playing gods and they have ultimative juristiction and ownership over
    our bodies and minds!This is conspiracy of New World Order and Icke’s only one,who have any clue what is really going on!Mind manipulation is what Psychology and Psychiatry are all about.One with psychotheraphy,another
    with psychotropic meds.

  5. No offense, but it is mind boggling that people can read Whitaker’s books, understand the truth, and still perpetuate the same nonsense that psychiatry has been peddling for decades. Simply. Mind. Boggling. Why is it still unclear that the sooner psychiatry is eradicated from the face of the earth, the sooner health will bloom and grow? Baffling. Just. Baffling. Heaven help us.

  6. Your original narrative sought drugs that could erase natural emotional suffering from unusually distressful experiences as if it were a disease. Your emerging narrative of “recovery” continues to advocate that mental distress is a medical problem (biological dysfunction) while improving care through efforts to increase the social welfare of clients. I consider mental distress to express natural emotional suffering from distressful experiences (or “anti-social” reactions to the suffering) – a social welfare problem rather than a medical problem. Social welfare problems can be caused by physical issues like poor nourishment, fatigue and toxins but most emotional suffering is caused by unusually distressful experiences. Treating “disruptive” expressions of natural emotional pain from extremely distressful experiences as a disease promotes coercion that increases emotional suffering- worsens mental distress.

  7. Italy already have Mental Health communities,but this only eliminate Mental Institutions-Asylums.
    So,if anyone think that this should be the way to go then,no it’s a way for continued existence of Mental Health System.And control and manipulation of crazy population there,will still go on.With psychotheraphy and also with
    psychotropic meds.Of course Mental Health experts won’t agree with me,but they know that Psychology and Psychiatry are both against biology and evolution.