The myth of the abduction of psychiatric care

http://www.peteearley.com/2016/04/22/federal-agency-that-delivers-mental-health-services-doesnt-believe-serious-mental-illnesses-are-real-huh/

There is a widespread myth that for many people is accepted as automatic truth. Psychiatric care, in a real way, according to them, has been abducted by the actions of unscrupulous people who care nothing about the most vulnerable amongst us. Their actions are borne of selfish motives that seek to benefit themselves at the expense of the needs and welfare of the “severely mentally ill” It is a destructive myth to the degree it drives many people’s call for mental health reform in a direction that only makes things worse for the people they claim they want to help.  

The post linked above is only one example of an appeal to that myth that would have to back to a system that we largely junked because it was abusive and hurtful to many of the people it served.  It was a financial monster gorging itself on the resources of many mental health systems and making it impossible for them to develop alternative services.  

But most of all it didn’t work.   It didn’t offer people a better life.   It didn’t offer resolution of critical life issues.   It told people that hope was an illusion for them,  that misery was the most realistic option for their life and they would help them manage that misery.   It gave them a diagnosis that would follow them forever that their own studies show had little validity or reliability.  It gave them medicine that frequently didn’t work and when it did they largely didn’t know why.  It gave them medicine that for many had life threatening or life altering effects. It cost many people years of their lives. It provided the apology for a culture that belittled and shamed the “mentally ill.” “Mental illness” was for many the definition of their life. They were often poor, often hungry, too often either homeless or in jail, lacked any access to decent health care and that is only scratching the service. The injustices, the hurt, the trauma of their lives were explained away or justified by reference to their “illness”. The injustice in their life according to the psychiatric vision was a consequence of their illness and psychiatry in some ways became an apologist to the worst of our culture. For many the reality of their experience was much more assault than illness.

The myth has some differences or variations depending upon who explains it. It is the foundational myth of the Murphy Bill. It is the pillar everything else rests on.

It goes something like this :

Psychiatric care has been abducted. It has been stolen. The treatment based on sound medical truths so essential to the lives and welfare of so many poor suffering people with severe mental illness is no longer available to them because it has been marginalized by people who have a vested interest in the notion of recovery and these people are willing to abandon and hurt those in the greatest need to feather their wallets and their ambitions.

Some versions of the myth are not quite this blunt and make some effort to blunt the paranoid or conspiracy theory quality of it but the message is clear. The people who should be in charge are no longer in charge and until we make things right the mental health system will never be what it should be.

There are a lot of ways to question this myth and many justified criticisms that can be made. I want to look just at one phrase….. the psychiatric treatment of severe mental illness. The reality of it has little to do with the romanticized “Hollywood like” notion of it.

Before I go farther a note on language. Despite what they say about ground breaking treatments and evidence based treatment I understand the term psychiatric treatment in this context to largely be psychiatric hospitalization and medication…. neither particularly new or evidence based.

1. Psychiatric treatment (at least in terms of hospitalization) has remarkably little to do with psychiatrists. Psychiatrists, in a very real way, exist to sign off on the work others do so the insurance companies will pay. I know of one psychiatrist who had 60 patients in one hospital. He got paid a $100 a day attending fee for each one of them. 3 hours of every day were those patients being lined up outside his office to be asked the same 3 questions: Are you sleeping? Are you eating? Do you feel like hurting yourself? Then he would dictate a note about the progress of their depression.

2. If you go to a psychiatric hospital the first thing you learn is that it is about power. You have none and life on the ward is about how you navigate the power above anything. The first sign a patient is making progress is that they don’t make trouble and how not to make trouble is the first lesson learned by most patients.

3. The course and length of your treatment is not defined by the progress of your mental health but by the willingness of your insurance company to pay for it. As long as they are willing for you to be there the people there will have no trouble finding something for you to work on.

4. Psychiatric hospitals don’t treat mental illness. Before you have a heart attack let me explain what I mean. Nothing is tailored to you because of your diagnosis. There is no diagnosis specific treatment. Everyone is offered the same cookie cutter, generic program. For many hospitals it is groups teaching the same prepackaged skills in the same way. If you “relapse” you get to do the same groups again.

5. The most predictable experience in any psychiatric hospital is boredom. For many hospitals therapeutic millieu is little more than sitting in the day room watching TV. But rather you watch TV or not long periods of having absolutely nothing to do are characteristic of a large amount of hospital programs.

6. Psychiatric hospitals thrive on the dependence of the people they serve. Particularly for profit hospitals survive in a big way on the return business of those they have previously served. The message is clear… this is a long term thing and you will likely need to see us again. It is much easier to get somebody to come back for a second visit than it is a first one.

7. People who work in psychiatric hospitals want to help the people the people they serve but psychiatric hospitals don’t admit people because they can help them. They admit them because they can get paid for them. There is no such thing as refusing admittance to someone they think they cant help if they know they can get paid.

8. There is perhaps some evidence that psychiatric hospitalization is an evidence based practice. I just have never seen it or heard about it.

9. Psychiatric hospitals did not fade because of some evil conspiracy. Too little bang for way too many bucks. It really is that simple.

10. Other than perhaps some psychiatrists I know of very little mental health professionals who believe hospitalization matters. Some see it as an important source for a temporary safe space for someone in need of a safe space but that is the limit. Again it is not a conspiracy. Just very few people drink the kool-aid any more.

11. For most states I know anything about increased psychiatric hospitalization is just not a real financial option. That ship has sailed and isn’t coming back.

12. The psychiatric role in the current system is to prescribe meds and sign off on the medical necessity of other people’s work. The idea we need to rely more on psychiatric input neither reflects the reality of the modern system or even the number of available psychiatrists.

Everyone wants a bigger piece of the pie and everyone wants to protect the piece they have. The romanticized notion of psychiatrist as healer and leader of the mental health system is simply an attempt to protect and enlarge a piece of pie. The reality of psychiatric care doesn’t come close to the version many would try to sell us.

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