Tools To Reduce Stigma of Mental Illness | Psych Central News

Tools To Reduce Stigma of Mental Illness | Psych Central News.

Violence and mental illness

Will noise win again?

“If nothing is right and nothing is wrong, then the only thing that matters is who yells the loudest.”– unknown

 

In the absence of principle man will pursue power with all the energy in his possession.  I read the above quote somewhere when someone was talking about what they thought was wrong with America.  What he was trying to say was in the absence of shared principles and ideas about truth, that there was nothing to talk about.  All communication requires a shared context and without that we can’t even disagree, because even disagreement implies a common ground to disagree over.  As a description of the current political scene I think he is absolutely right.  All is noise.

I remember during Obama’s campaign I used to sit and turn the TV back and forth between CSNBC and FOX.  What absolutely amazed me was that these 2 “news” organizations would describe an event and if you didn’t know better you would say that it was 2 different events.  It seemed to be 2 different worlds with each claiming to be the “only real news.”

What I liked most about Obama is that he seemed to promise that it was possible for principle to triumph over power.  He seemed to give promise that the loudest noise didn’t have to win again.  He seemed to say that politics didn’t have to be the art of calling your opponent the worst name that you could get the most people to believe.  I still like that.

I listened to Rush Limbaugh talk about how he hopes the president of the United States would fail.  I thought about how many people I know are going through really hard times and what that failure would mean for all of us and I knew what Rush Limbaugh thinks of me.  I knew he was noise and his only weapon was to render us all helpless in the storms of his noise.

Watching it all I am really concerned.  I am by no stretch of the imagination a political wizard.  What I don’t know would fill many large boats.  But listening to the start of the Obama time I can’t help feeling like so many people would be content if it was all a battle to see who could yell the loudest.

The truth is that some things are right and some things are wrong.  One of my favorite movies is one called the “Marathon Man” with Dustin Hoffman and Lawrence Olivier.  One of the things that Olivier’s character keeps asking Hoffman’s is, “Is it safe….Is it safe….Is it safe….”  If you have the misfortune to be sick and dependent on our health care system the answer for too many people is simple, “It is not safe.”  It sure seems like it should be.

The mental health system: the coming chaos

The mental health system is not making it.  It is trying to do too much for too many with too little.  And it promises to get worse.  Much worse.  The only hope that seems realistic at this point is if President Obama’s stimulus plan adds enough money to offset some very real budget cuts.

What follows is a description of Maryville, Tennessee where I live.  My hope is in Maryville you can find something that explains the situation that you are in.  I think Maryville is probably much better than many situations.  I am sure it is worse than others.  I do think though that there is something to be learned about all examples by looking at one.

First some basic facts.

• The Blount county area (includes Maryville) has about 113,000 people.  For a population of that size they should have about 13 suicides a year.  Blount county had about 26 this last year and is on pace to break that mark in 2009.
• There are 2 major mental health centers in the county.  A third has a more minor presence.
• The current assessment is that about 12,ooo people in Blount County are without insurance, but that number is rising.
• The jail has about 420 prisoners.  About 30% of those are on psychotropic medications.  That number appears to be on the rise.
• Although many people in the county are on TennCare, there are very few TennCare providers.  This is especially true in Mental Health since reimbursement rates are so small.  Many providers including inpatient psychiatric hospitals are trying to decide if they can “afford” TennCare this year.
• There have been major loss of jobs.  With that is a rise in uninsured.
• Sometime in the spring about 150,000 Tennesseans will lose their insurance.  About 20,000 of them will have major mental health diagnosis.  The portion of these people who come from Blount County is unclear.

If you view mental health as being as much a community issue as you do an individual issue it is not hard to see where all this seems to be going for Blount County:

• If the accepted estimate of the prevalence of mental illness is true in Blount County that means that about 25,000 people a year suffer from mental illness.
• Because of the low rate of reimbursement for TennCare there are no private practice  psychiatrists in the county who accept TennCare.
• There are somewhere between 4-7 private practice therapists who accept TennCare.   Most of them are not accepting any new patients.
• With the rise in unemployment and the loss of TennCare coverage  there will be a rise in the number of people needing  mental health services who are either under TennCare or who have no insurance at all.
• Currently there is a 6-8 week wait for psychiatrist appointments at the mental health centers.
• One of the larger mental health centers has made the decision to at least temporarily close the door to new patients until they feel like they can get a handle on providing better and more timely services to the patients they do have.
• Even though the amount of uninsured should rise the state has made the decision that TennCare will no longer pay for services they had been paying for  under the assumption that they would qualify for TennCare (the state only category).  They will also no longer provide reimbursement to those who are judicially committed.
• As times get harder it seems likely that more and more people with mental health issues will end up in the correctional system.  The 33% of prisoners on psychotropic meds should rise and the Blount County Jail will remain the largest treatment facility in the county.

Many people will not just fall through the cracks.  They will live there.  The mental health centers will get hit with a tsunami of demands at a time when they are having greater and greater difficult dealing with small waves.   The possibility of tragedy both on an individual level and on a community level seem very real.

Maryville is a great place to live and has many strengths.  They have a dedicated and committed mental health system.  They are aware of what is headed there way and seem to be trying to get ready to deal with it.  But given the facts as I have shared them what chance do they really have?

What really scares me is that I am afraid that Maryville is a best case scenario.  A lot of other communities are probably looking at much worse prospects.  It is a scary thought.

And I was sick

For the very first time last night I watched Michael Moore’s “Sicko.”  And I was sick.

For some reason I had always avoided it.  I am not sure why.  When it started I didn’t expect much, but decided to watch anyway.  Even allowing for his excesses and showboating at times, what I saw last night was heart crushing.  We are killing each other.  Insurance companies do business by trying as hard as they can not to insure anything.  Ordinary people who have the misfortune to get sick find out that they have less protection than criminals.  In Tennessee if you have no insurance and are sick I sometimes wonder if you need to consider going to prison where you will get the care you need.

We pride ourselves on being the most advanced and civilized place in the world, but a bunch of other countries understand something we don’t.  Life is about we and not about me.  Certain things should be automatic.  Health care is one. We shouldn’t have to worry ourselves to death.

If you haven’t seen it see the movie.  See if you don’t get sick too.

Red alert: What you need to know.

It now appears that Tennessee governor Phil Bredesen is on President Obama’s short list to become the next Secretary of Health and Human Services since Tom Daschle has dropped out.  This would effectively give him control of what happens in health care in this country.  This would be past a tragic mistake. 

In the past few years over 250,000 low income working Tennesseans have been dropped from TennCare the state insurance.  As bluntly as possible, people have died while Governor Bredesen paid due diligence to his bottom line.  Intitially there was a safety net for those who lost their insurance, but that is effectively gone.  Another 150,000 are getting ready to lose their TennCare in the next couple of months.  In place of this Governor Bredesen has created a program called Cover Tennessee which serves 20,000 people.

In Tennessee it has become for many who are poor and sick a scary time.  Governor Bredesen used to run a healthcare company and given the state of the current health care system do we really want to put the fox in charge of the chickens?

There are a lot of qualified people.  You need to speak now.  The email for the president on this issue is:  www.whitehouse.gov/contact/ .  Please speak out.  As bad as I hate to say it as a resident of Tennessee lets keep Phil Bredesen home.

Speak up

Now is the time for anyone interested in mental health or health care reform in general to speak up and speak up loudly.  The Republicans have shown that they will do all they can to derail Obama’s stimulus plan.  The plan is not the answer to all things by any means, but hopefully it will start momentum in a growing and positive direction.  It is time our representatives hear from all of us.

According to Mental Health America the stimulus plan includes real money that would be applied to Medicaid funding which might help stop the blood flow a least a little in state budgets.  They indicate their is an additional $18 billion in funding for other health care plans.  It is a start.

Also realize politics is very much a matter of momentum.  Later this year Obama will probably be ready to implement his plans for health care reform.  The things go between now and then will influence greatly how his health care plans are received.  Do what you can  to help prepare the ground.  Success now prepares the ground for success later.

Make your voice count.

The stereotype of mental illness and violence

Another blow has been struck against the stereotype of the “violent crazy person.”  This is a belief held by many people.  Just read any local paper after a violent crime.  In a dressed up way this belief is also the centerpiece to the argument of people like the Treatment Advocacy Center.  It is a centerpiece assumption that lays underneath the stigma that those with mental illness deal with every day of their life- the idea that somehow they are diminished people that less should be expected out of , that should expect less from us.

There is an article in the General Archives of Psychiatry by Dr Eric Elbogen of North Carolina.  The study followed 34,000 adults.  Its conclusions were clear.  Mental illness, unless it is paired with substance abuse, a previous history of violence and several other factors is not predictive of an individual’s likelihood of violent behavior. 

I think we have known this, but to hear it being reinforced on such a grand scale is great.  As someone else pointed out mental illness is probably a greater predictor of being the victim of violence, rather than the author of it.

Maybe the next time there is a horrendous crime and we try to solve it by saying “He must be crazy” someone will stop and say— maybe there is more to it than that.  Calling names explains little other than you believe it does.

Another voice on mental health

Many people I know refer to themselves as “survivors” of the mental health system. 

Their experience with hospitalization was often to be diminished as a person and relegated to the status of a “crazy” who will never do better.  For too many their experience was to be either emotionally or physically abused. 

They are in deep conflict about their medications.  On the one hand many realize that without them they are unlikely to function well.  But many medications have with them radical side effects which make their daily life more difficult and in some cases side effects that may effect their health adversely for their entire life.  Every day there seems to be a new story about lies or outright fraud perpetrated by major pharmaceutical companies. 

Outpatient services for many are not easy to find.  For those who find them the demands normally outstrip the resources and they find themselves caught in a program with long waiting periods which at times seems more to endure them than to welcome them.

There is a different voice on the subject though.  The Treatment Advocacy Center believes that consumers have too much voice now and that stricter measures need to be taken.  They believe for example that we should make much more use of psychiatric hospitals.  They think that there should be 50 beds for every 100,000 in population.  For Tennessee if I have done the math right that would mean about 3000 beds.  With the current budget crisis the state plans to have 692 beds and cut outpatient services while they are at it.

They do not believe people should have choices about treatment either.  They believe in “assisted outpatient programs.”  This means if you refuse to take meds or participate in treatment and it appears you will go further downhill without treatment, that you have trouble meeting basic needs, you are a danger to yourself, or a danger to others that you can be court ordered to take meds/treatment or be locked up until you do.

They believe that about 50% of people with serious mental illness have anosognosia which basically means they are not aware there is something wrong.  They say this is biologically based and part of the mental disorder and because of it we can not be too concerned about what they want to choose in regard to their treatment options.

There are a bunch of problems with all of this:

• The TAC keeps a catalogue of all the violent acts they can find committed by “emotionally disturbed ” people and tries to say that lack of treatment is the cause.  This scare tactic conveys the idea that in some way the mentally ill are more dangerous and violent than “normal” people.  This is simply not true and greatly reinforces a stereotype which reinforces the stigma about mental illness.  Violence is not an emotional illness issue per se.  It is a people issue.  Meaness and cruelty are not psychiatric categories.  If anything they are moral categories.
• The whole idea about anosognosia has tremendous holes in it.  First of all it assumes that not doing what your doctors say and not knowing you are sick is the same thing.  If you are bipolar and you have went 10 years being diagnosed incorrectly you are likely to grow a healthy skepticism about what any doctor says.  Maybe I don’t know the right people, but I have never met anyone with bipolar disorder that doesn’t know that something is very wrong.  Might they have personal moments of blindness about their problems.  Sure- but don’t all of us have that.  We all have the ability to rationalize and close our eyes to the most stupid and self destructive things in the world.  That is not confined to those with mental illness.  They say that this anosognosia is because of problems with the right hemisphere.  Where exactly is the evidence that bipolar disorder or any other disorder is a disease of the right hemisphere.  I think in the end doctors believe that anyone who doesn’t do what they say must be mentally ill.  It seems more a matter of the personal blindness of medical professionals than the blindness of mental health consumers.
• Related to the above- The TAC prescription implies that treatment is a cut and dried, black and white affair.  It isn’t.  It varies widely from doctor to doctor.  They can’t even agree what is bipolar and what is not.  Medication is for sure not a cut and dried affair.  When you are being given a medicine that may cause diabetes, heart problems, obesity and many other life altering events how can you criticize anyone who is reluctant to take those meds– even if they do help. 
• Their proposal would result in a radical increase in the number of people in psychiatric hospitals.  This goes against everything that has been discovered about the dangers of institutionalization.  There is very little evidence of the efficacy of hospitalization.  It further perpetrates the myth that the mentally ill cannot function in the real world and by doing that drastically increases the stigma of mental illness.  I think it is that stigma that makes people hesitant to seek treatment and thus the TAC would be making less likely the very thing they say they want.  
• Because this system would rely so much on compulsion and force it would create a system that would be very easy to get into and very hard to get out of.  We already have a system like that.  It is called the correctional system.  Look how effective that is.
• These suggestions are so far out of touch with the economic realities of the world as to be psychotic in themselves.  They if anything are likely to have a rebound effect.  The system they describe would be much larger than the present one.  Because their solutions are simply not realistic I wonder how much it would make people think the problems are also not nearly as bad as made out to be.  I think serious consideration of these proposals would take attention away from much more practical and realistic ideas and make it harder for anything to be done.

The mental health system is in crisis.  In that the TAC is exactly right.  It is true that sometimes people are dangerous and we all need protection from them.  However their ideas go far past that.  They make assumptions that are simply not true or based on dubious assumptions or studies.  They go much further making mental illness as being even more a source of stigma than it is now.  In that alone they pose a real danger to anyone who struggles with mental health issues.

What we can’t afford to not afford

I heard a state legislator ask his colleagues one time, “How long can we afford to delude ourselves?  We work so hard to control short-term costs because we can’t afford them, but in the process ignore long term costs that are destroying us.”

I think it is a little like trying to figure out how to safely swim in a river of alligators rather than trying to figure out how not to get in the river.  Eventually the gators will get you.  Our health care system can’t figure out how to get out of the river.

Just looking through the papers is like watching a disaster unfold.  We are worrying about asteroid dust, while the big meteors are headed directly towards us.  Just look at a few of the events:

• Unemployment continues to rise.  Most states report a 5-10% rise in Medicaid.  They can’t pay for what they have now.
• Those who have jobs are finding health costs spiral through the roof.  They are eating up more and more of salaries.
• More people are deciding which medication to take or if they can take medication than ever before.
• Some doctors are reporting increases in sickness, because people can no longer afford the food or other things they need to live a health life style.
• As stress increases the need for mental health services are rising.
• The budget for mental health services is decreasing rapidly.
• No one knows which business is going under next.
• Without mental health services effectively provided the jails, the homeless, and suicides are sure to rise.
• The papers are littered with stories of big pharmaceutical companies employing deceptive practices to people that don’t work near as well as advertized and which in some cases leads to disastrous side effects.
• The medical system is seen by too many , not as a source of opportunity to make their life better and longer, but as a source of deprivation only their to line their own pockets at the expense of ordinary people.

And then recently I saw another story.  A group in California had done a study that showed that the movement to a single payer system would add over 2 million jobs, as well as having  considerable other positive economic impacts.  And that doesn’t include what it would do for the general health.

There is something we need to understand and make sure our folks in government both understand and act on.  Health care reform is not what happens when the economy gets back on board and we can “afford it.”  Health care reform is a major part of getting the system back on board.

We don’t have to swim with the gators.  There are other rivers.