Monday, March 27, 2023

Comments by Shrink

Showing 4 of 4 comments.

  • I actually believe changing the system is simpler than most think. Unlike many, I do not believe we suffer from a lack of resources or providers of quality mental health services. Instead, I think we misuse those resources to a staggering degree, leading to an inefficient and arguably unethical degree.

    I worked at a large county jail for several years. When I arrived (I’m a psychologist), the system was you would expect: very psychiatry-heavy. The social workers and psychologists were glorified baby-sitters, putting out fires, but doing little actual clinical work. Any inmate who hinted at a mental health issue was referred to the psychiatrist, who naturally had a hopeless backlog they would never get seen in 20 years. Every inmate referred was given whatever medication they felt they needed/wanted and we were spending something like $50-60k per MONTH on psychiatric medications alone.

    Me, being the radical shrink I am (proven by my following and posting here!) suggested a “radical” shift. Let the clinicians already on staff do actual clinical work. Let’s (wait for it) ASSESS people to see if they really are mentally ill; to see if they actually need medicine or not. We let social workers do what social worker are best at. We let psychologists do what they are best at. And we reserved our psychiatry hours for those seriously mentally ill people who really needed it.

    What happened? It worked. We provided good quality mental health care to a huge amount of inmates. All were given quality assessments and although everyone of them thought they were mentally ill, most weren’t. We provided therapy for those who wanted it, and for the small percentage that was left, we referred to psychiatry. No more backlog. Over the course of 18-24 months, we reduced our psychiatric medication budget to 20k or less. We did not hire more staff. We did not throw more money at it. We simply rearranged the existing resource in a sensible, ethical way.

    We saw no increase in behavioral problems; no suicides, and we certainly did not have a bunch of decompensating, unmedicated mentally ill people flying the the rooftops of the jail. It worked because it makes sense. Most people need lesser interventions; we should use them. The research shows they help, they work, and most benefit. Instead, we tend to use the most invasive (usually medicine) first and non-medical mental health professionals scrape by on the crumbs that are left.

    I am absolutely convinced the system could change, but of course psychiatrist’s and other medical doctors’ egos will prevent it, as will pharmaceutical dollars and politics.

  • Great article. And very on target. I think the other factor is for those of us who are professors and instructors to teach and promote these ideas and resources in classrooms. I find each new semester that my students have grown up drinking the kool-aid and have never heard the radical ideas I am teaching them about. By the end of the semester, many of them are thrilled and curious. I suspect this can be a very effective method for increasing readership/exposure, but also shaping a new generation of professionals.

  • As others have said, articles like this beg the question about whether so-called “treatment” helps. The presumption in expanding Medicaid (or other insurance services) is that by granting “more access” people are better off. But the care they are accessing is awful, harmful, and probably decreasing their mental health. As such, I suspect not expanding Medicaid is HELPING people get mentally healthier. We obviously need major changes in care so we can provide good services to the people who need it.