A Response to DJ Jaffe's '8 Myths of Serious Mental Illness'

The following is in response to a post by DJ Jaffe, titled "8 Myths About Serious Mental Illness."

1. All mental illness is serious: A red herring

I don’t think most people, public administrators, or public clinicians do think that all “mental disorders”, conditions, or situations are created equal or with equal seriousness.  

Further, the public funding for mental health is very complex and comes from multiple sources.

• The state funds mental health institutes and prisons.
• SAMHSA provides block grants to the states to provide some funding to the community mental health centers.
• And the Big Kahuna is Medicaid – a state and federal partnership.

Further:

1. There is what I call straight Medicaid that has traditionally served individuals on SSI. Medicaid brings with it community mental health services; AND
2. For people with the most serious mental health situations there is Medicaid Long Term Care which can include Medicaid home and community based services.

2. Violence is not associated with mental illness:

It is not as if one could simply identify all the people with schizophrenia and bipolar disorder and say they would have a propensity for violence if not treated.  

Further, many studies have found a correlation between ADHD and criminal behavior, and not everyone.

Many states probably have statutes such as Colorado which provides immunity to mental health professionals in their assessments of danger to self or others, etc. In those cases that go awry, mental health professionals are quick to say that there really is no way to make these determinations.

Of course, it doesn’t stop these same professionals from going into court and testifying under oath that they can make such determinations with reasonable certainty.

Just one of the little fictions our society likes to tell itself because the truth is far from comforting.

Are there people who are violent who have “mental illness,” traumatic brain injury, developmental disabilities, whatever? Yes. And if we treated those folks under Medicaid it would be a lot cheaper for the states.

3. Stigma is a major impediment to care: (D.J. argues that cost is major impediment to care and we agree.)

Folks who are homeless or at-risk of involvement with the criminal justice system generally represent “high end users” in Medicaid’s capitated mental health program which means it is going to cost the community mental health system to serve them.

Services such as Assertive Community Treatment (ACT) and Intensive Case Management (ICM) which are expensive should be available to all where such services are “reasonably medically necessary.” I believe that failure to provide such services violates due process, equal protection, and the ADA.

4. Psychiatric hospitals should be replaced by community services.

I believe in a continuum of care. In Colorado we closed a geriatrics unit and a children’s unit that were desperately needed. These closures were done as a result of budget cuts and we were assured that the “rich resources in the community” would take up the slack. Of course, that didn’t happen. People got put in nursing homes that don’t have the expertise to deal with people with mental illness and kids and their parents got stuck in emergency rooms.

Additionally, people in the institutes get “stuck” because their clinical team determines that they are ready for discharge but there is nowhere to go.

We need a continuum of care that includes several levels of care that individuals may move through easily as needed and desired.

5. Treatments that are involuntary are bad by definition: 

A lot of mental health advocates will disagree with me – and I believe that "anosognosia" -- not recognizing one is "ill" -- sometimes is a complicating factor– AND a huge complicating factor is that our treatments aren’t that great.

One can easily have a person who has been delusional for years, maybe even decades, perhaps exhibits "anosognosia" – and the ultimate result of involuntary treatment is PTSD and the delusions are still there.

On the other hand, there other people who might thank the treatment team for helping them.

I’m not aware of any reliable way of determining who is who.

I think what that means is the critical importance of “relationship.” Even those folks who don’t want mental health treatment, generally do want “help.” Providing “disability services” through the Independent Living Centers may be an acceptable and viable option for some folks.

6. People with mental illness are more likely to be victims than perpetrators:

Let’s just say this is a ridiculous debate and move on. We probably can't even agree on what "mental illness" is -- AND that is not necessary to recognize that some people are having great difficulty and need "help."

7. Serious mental illness can be predicted and prevented:

I think the argument is that SAMHSA allocates a lot of money to prediction and prevention of mental illness – but serious mental illness can’t be predicted or prevented.

Without specifics it’s hard to comment. From my perspective Medicaid, not SAMHSA is the big funder of public mental health services so I would not see this getting to the “root cause” of any problems in mental health funding.

8. Everyone recovers:

I agree that we have to fund science and the National Institute of Mental Health. I don’t think anyone can take the DSM seriously as a scientific document in 2014.

While well-intentioned, the Murphy bill is out of touch with the realities of public mental health financing and the needs of the people it is trying to support.

Orchid Mental Health Legal Advocacy of Colorado would welcome the opportunity to collaborate with the Treatment Advocacy Center and the Mental Illness Policy Organization to better serve the needs of individuals perceived to have mental illness who are homeless, at-risk of incarceration or incarcerated.

Congratulations to D.J. Jaffee for bringing this critical debate to the forefront!

Image courtesy of Ashley Rose via Flickr.