Kidding Ourselves

During a wonderful lunch today with Dennis McCrory, the original psych rehab psychiatrist and long-time consultant to the Massachusetts Rehabilitation Commission, he asked what I thought of MRC, our federal/state rehabilitation agency, and I, of course, digressed, sharing thoughts that had been occupying my mind for the previous week, just waiting for someone to come along and make them relevant.

During our careers, early on in mine, two models of community day programming for people with psychiatric conditions dominated: day treatment and sheltered workshop programs. I spent a good deal of my career campaigning to have these particular models replaced by ones I believed to be more enlightened: clubhouse and supported employment. [Of course, these have since come to be seen as old fashioned, to be replaced by outreach teams and peer support, but that’s another story.] In the process of watching and occasionally participating in conversions and program closures, I noticed something that disturbed me more and more. Whereas we enlightened geniuses were convinced that our approaches would serve participants in these old fashioned programs much more effectively in our new-fangled ones, it always seemed that only a handful of the participants made the transition to those newer services. The rest simply disappeared. Since the people running the services moved on as well, it was as if the former participants had never existed. Let’s go back another step.

We hear repeatedly of the prevalence of people with schizophrenia and related thought disorders (or for those so identified, for the more enlightened among us) as 1% of the overall population, with another 1% for people with mood disorders. That’s two in every one hundred, without even getting into addiction and developmental disabilities. I always believed these statistical projections suspect because, if you do the math, you come out with huge numbers of people—orders of magnitude greater than any served in our treatment and support systems. It got me thinking of the old story of the blind, or blind-folded, people presented with an elephant. Depending on where they were standing, they would conclude that the shape and nature of the animal was different, and none could imagine the true size of the creature.

We do the same thing. People running prisons think they are dealing with most of the people with serious mental illness. Another psychiatrist for whom I have tremendous respect was convinced that if you had a psychotic condition it was impossible for you to live in Boston and escape treatment at some point. People running homeless shelters are convinced that they are the primary treatment resource for most people with such conditions. If you do the math, and project the numbers of people out there dealing with these issues, you have to conclude that each of us is focused on a tiny sliver of a very large pie, even though, because of the way our minds work, we easily slide into the (lazy) conviction that we are seeing most of them, or at least a far greater proportion. We’ve got this. Yeah.

Seen in this way, certain conclusions become evident. People who did well in day treatment programs and workshops didn’t do well in other models, and were replaced, from a huge pool of candidates, by people who did better in clubhouses and supported employment. Each service type attracts a tiny subset of the total population they are designed to serve—that’s just the way it is. And most people go unserved.

Years ago, I noticed that the state Department of Mental Health had only a few remaining ‘front doors’ into services. I expressed this concern to the Central Office—it might have been to then commissioner Mary Lou Sudders (my favorite DMH Commissioner), I’m not sure—and suggested that it would make sense to create more front doors in order to make services accessible to more people. The response was something like this: “Are you kidding? We have more people to deal with now than we can handle. That’s the last thing we would ever think of doing.” We know that most people settle for getting a pill from their general practitioner. Parity? Can you imagine what it would cost to give everyone a therapist? What is this, the seventies?

So here’s what I conclude:

• People need a range of different approaches to find one that works for them, but our systems are biased against providing them.
• Our systems are determined to narrow the range of people served, to try to select the best candidates to succeed in the services we want to provide.
• In the process, our systems have a strong interest in denying the existence of everyone else, in part in order to restrict eligibility to a manageable number but also to maintain our illusion that we are somehow close to meeting an identified need.

All of which was to say that MRC has such a broad mandate and such a tiny bit of funds to carry it out, that it’s no surprise that they place huge obstacles in front of those requesting their services. Only those who find their way near them, are sufficiently impaired to qualify for priority services, can tolerate a long and arduous procedure and then quickly use a few services to move into sustained full-time employment, are deemed to qualify. From the outside, this is a vanishingly small number, but it’s still enough to overwhelm that tiny agency.

And one last thought. Our gun-control advocates talk often of keeping guns out of the hands of the ‘wrong people’—you know, criminals and crazies. In regard to the latter, they often reference ‘our failed mental health system.’ Here’s someone with obvious problems, why weren’t they treated/monitored/controlled/locked up so they couldn’t perpetrate this awful crime. A recent case in point in Massachusetts involved a series of fatal knife attacks by the same man on the same day, after he went to an ER requesting treatment and was released rather than hospitalized. He had a recent history of crazy and suicidal statements, and a quite remote history of threatening behavior—there was a girlfriend’s restraining order—and a couple of fist fights. Why wasn’t more done by the mental health system?

People asking that question have no idea of the size of the pool of people who displayed those warning signs and much worse. Even if we could predict who among them was likely to go from a few odd statements and suicidal thoughts to a lethal attack—and no one has yet demonstrated that ability—what would we do? Politicians and journalists will continue to refer to ‘our failed mental health system’ until somebody bothers to run the numbers and figure out that improvements will only come from increased funding and setting painful priorities. And even then, improvements will be incremental and will never address the issue of mass shootings and other rare tragedies people associate with mental illness.

Anything more ambitious? We’re kidding ourselves.