I’ve come to a realization: I seem to have become a kind of bridge over the troubled water of mental health care. In other words, my role within the Mad in America community has been to provide a perspective largely conditioned by six years as a state mental health commissioner. What does this mean and how did it come about? And what good might come from it?
First, what does it mean? I’ve observed for some time in the Mad in America community that I think differently than most others. I believe that, realistically speaking, psychiatry isn’t going away. State legislatures are not anywhere near abolishing involuntary “treatment.” The mental health “system” will not be reformed in the short-term. Cultures in everything from state hospitals, to community-based inpatient programs, to crisis services, to outpatient settings don’t change quickly.
Changes require not only culture change but also financial considerations, rethinking policies, revising practice standards. If we are going to improve care, we will not destroy it any time soon. So maybe I am a hopeless reformer. And maybe the view of me as overly comfortable with current realities represents a dangerous complacency on my part.
Every time I post a blog, I get pretty severe criticism from people who I respect for the purity of their vision but who I see as too far outside the realm of systems to actually have much impact on them. As I noted already, they do keep me and others from getting too comfortable with current practices. My return concern about their position is that while it may help with ventilating completely understandable grievances—the system really is very destructive in very personal and important ways—it leads nowhere that I’ve seen.
I find myself asking questions like these: What changes are needed in terms of policies, legislation, administration, clinical standards, training, political alliances, advocacy at local, state and federal levels to accomplish these reforms? Will some of these require legal interventions like lawsuits or court challenges? Is investigative journalism a piece of the puzzle? Do we have connections with newspapers or radio or television resources? Are there members of the media who could speak up from their personal experience? Is there progressive and courageous leadership inside the system anywhere? Are there people with lived experience who can speak personally and articulately to things that damaged them as well as things that worked? What would the changes and change processes cost, who would pay, and over what period of time?
Can we craft alliances with progressive professional organizations like NASW, Doctors for America, the American Psychological Association? What about our friends like NARPA Disability Legal Rights Center, ISEPP, and the Psychiatric Rehabilitation Association? Then, getting a little outside our usual circles, what about the National Association of State Alcohol and Drug Abuse Directors (NASADAD), Doctors for America, or the National Association of Counties (NACo)? Could we somehow engage the conservatives like the National Council on Behavioral Health or the National Association of State Mental Health Program Directors?
What if we developed plans with timelines to move an agenda forward for change? Where will resistance to the changes come from—the American Psychiatric Association, law enforcement circles, NAMI? Are there private foundations, philanthropists or non-profit organizations like the Foundation for Excellence in Mental Health Care that might become involved one way or the other? How do we come up with meaningful ways of messaging that get through to more than us as a “choir?”
What are key leverage points to consider? For example I’ve advocated that honest and accurate informed consent for the prescribing of psychiatric medications is an important one. Another would be greatly expanded professional education resources like our Mad in America Continuing Education project. Are there institutions of higher learning to confront and how would we do that? What about amplifying peer certification approaches and are there risks?
In my experience as a state mental health (and addictions) commissioner, these kinds of considerations need to be hammered out at local, regional, state and national levels. They take time. They usually require taking advantage of opportunities like public fears and scandals, fiscal and other crises. None of this happens easily. It takes more than anger and outrage—as important as these are at various stages of the game.
So, have these kinds of approaches worked anywhere? I think so. There are examples of public funding for Open Dialogue adaptations. These came about through local leadership taking advantage of private foundation resources and then converting pilots that started in this way into community mental health budgets.
Another instance is a project, now 15 years old, in a state hospital. It started with two key state level leaders who knew of examples of peer delivered services and turned this knowledge into a Peer Services Recovery Department.
A third progressive reform is a peer support system developed by a person with lived experience for people with both alcohol/drug and mental health challenges. It began with public forensic services funding but expanded with a variety of local community corrections support, public acute psychiatric finances and managed care funding. This latter peer-controlled service grew through strong private nonprofit leadership taking advantage of the increasing interest in the recognition of people with mental health challenges who end up in hospitals, jails and prisons. All of this has been stirred up by heightened media attention to the crisis.
I doubt that this way of looking at system change will please everyone in the Mad in America world. In fact, the dissenting voices keep us possibly hopeless reformers from being naive about the damage that has been done for decades and centuries. The tension is real, but anger alone will change nothing. Believing the system will be abolished is totally unrealistic. It is critical that we do a better job of translating the desire to move away from the medical model into a more pragmatic and successful approach. We have major challenges ahead if we want to reduce and eventually eliminate forced treatment, dismantle the false belief that medications restore chemical imbalances, and establish creative practice reforms like Open Dialogue.
I do hope that outlining my difference in approach will be of some use to those who want to see concrete improvements in culture and practice take place and lead to meaningful and substantial directions to reduce abuse, discrimination, and malpractice in a psychiatric world that is extremely dysfunctional.