The Honorable Joseph R. Pitts: The Wall Street Journal wrote an editorial recently that raised some concerning issues about SAMHSA's effort to address serious mental illness. Will you discuss what the federal government can do to improve the mental health delivery system, such as using more evidence-based care models?
Dr. Michael Welner: The most important change is actually ideological. Serious mental illness needs to be taken seriously. The time has come to engage serious mental illness as if it is cancer and crisis psychiatry as if it is a medical emergency. Approaching serious mental illness and crisis psychiatry any differently enables denial to perpetuate the morbidity to the individual and impact on every one of his or her dependents and orbit.
Those who disagree are in intellectual or personal denial. Is that any different from those with cancer or a medical emergency who have the same reasons for denial? The federal government does not have the same luxury, or we would not be engaged in these proceedings.
Unless government begins with this simple ideological change among its mental health leadership, service delivery to those with serious illness and in crisis will be inefficient, reflect poor prioritization, strangled by political correctness, outdated, unable to respond to new challenges such as disasters or dynamic research progress, and handicapped from thinking creatively to solve problems quickly while longer term solutions are being gradually put into place.
Engaging serious mental illness and crisis psychiatry with urgency will infuse a necessary rigor into the study, treatment, and quality control of conditions and situations. Leadership that does not suffer foolishness, ineptitude, poor performance, and non-science gladly will be the best thing those with serious mental illness could ever hope for.
Moreover, it actually is the most important leadership ingredient to serious regard for the civil rights of the individual and public safety. Petty battles over fighting commitment so that a released person, or one not admitted to AOT, can ultimately be incarcerated the next time they become a nuisance, or put in a morgue when attacked by bored marauding adolescents who encounter them homeless, needs leadership that treats those with serious mental illness as people who matter but have diseases of insight that are eminently treatable. A society that decides that it need not mingle gun debate to fix crisis psychiatry can finally admit that outpatient commitment would have prevented Adam Lanza’s destruction, and that such leadership would have prevented the political correctness that enabled Nidal Hassan and the terrorism of a person on the edge.
Government also has to decide that it is committed to psychiatry as a treating medical discipline. The recent editorial in the Wall Street Journal, “The Definition of Insanity” spoke of the problem of a SAMSHA budget that has so many resources allocated to experimental and unproven approaches. It highlights allocations to self-help programs that renounce established treatment and are inherently anti-psychiatry, and in the process neglect serious treatment of serious illness in favor of approaches better reserved for minor conditions.
With that said, this editorial only alluded to the bigger problem: that the anti-psychiatry of some sectors of SAMSHA’s emphasis, the allocations to experimental programs suited to those with minor emotional problems, or to programs that essentially promote the renunciation of treatment reflect a leadership philosophy promoting denial of the seriousness of serious mental illness, and the urgency of crisis psychiatry. It is the definition of insanity to have such an important national imperative presided over by leadership that actively pretends such problems do not exist or are not that serious.
Denial allows serious mental illness to drive the disease and to drive the crisis. It abdicates leadership not to individual rights, but to a serious illness. Those who disagree do not believe serious mental illness to be that serious. In the case of drug and alcohol addiction, and of serious mental illness, the illness itself is an ingredient of denial.
Those who manage urgency incompetently are unfit to lead. Those who refuse to acknowledge urgency are unfit to have such responsibilities in the first place.
We will make no progress in the delivery of services to the seriously mentally ill until we repudiate its denial with the same determination that one must show to cancer, HIV, and to drug addiction. Those illnesses have demonstrated to us that placating the “oncology consumer,” “infectious disease consumer,” “illicit substance user” inevitable imperil the very person we are trying to respect, after dragging those around him down first.
Some of the loudest discussions against HR 3717 have been led or instigated by those who consider themselves survivors of psychiatric care. Their personal stories and those of the clients they represent, as attorneys, may be wholly correct and contribute to their denial of the legitimacy of psychiatry as a treating medical discipline. But to transform their disappointments into mental health budget and program decision making is no different from empowering those who suffer surgical malpractice and are therefore opposed to invasive medicine to control the budget allocated to surgical medicine in America. It is insanity. These experiences neither generalize nor define the medical discipline. Rather, they are a byproduct of bad treatment decision-making, which is precisely what funding evidence-based treatment prevents.
Once the appropriate leadership is presiding over the budget allocated to treating those with serious illness, there are other necessary measures. One critical step is to act on the current reality that many in need deny their illness and would not participate in treatment even if it were available to them with every convenience attached and every cost to them eliminated.
Current American challenges in the treatment of serious mental illness and those in mental health crisis include many such individuals in denial. To then turn away and to pretend that such individuals are not part of crisis mental health reform because of civil rights is denial.
Yes, illness is real, and you’re sick and need to get help! Denial is not only personally risky, but in responsible others, it is expedient cowardice. Public policy must reckon with the fact, as we do as physicians, that placating people’s sensitivities about their illness in the practice setting, whether it is cancer, HIV, emphysema, drug abuse, or any other serious condition, enables denial. The patient goes down the drain. It is no different in the legislative arena.
Approaches to such individuals MUST integrate law enforcement, corrections, schools, employers, families, civic organizations, and houses of worship as necessary partners of mental health and force multipliers. Consider, for example, how many lay volunteers, as young as teenagers, have saved lives on telephone suicide hotlines. Mental health delivery is at its most effective when it thinks beyond itself. A leadership that embraces urgency rather than denial must reach beyond mental health to implement mental health.
The consequence of untreated serious mental illness is enormous to the individual and to families and dependents. In the cases of suicide, with its frightening commonality, the material costs are huge. The costs of neglected mental health crisis may involve violence. And in exceptional cases, the community violence is so substantial that it rivals those of terrorist acts.
With that said, delivery of services will be enhanced by attracting the best and brightest to crisis psychiatry and to treatment of the seriously mentally ill. The discussions of HR 3717 are borne of recognition that there are not only huge numbers of underserved individuals, but shortages of qualified child adolescent psychologists, psychiatrists, physician assistants and other professionals with crisis intervention training, cultural literacy, substance abuse, psychotherapy and counseling training. A leadership vision that approaches this challenge will create growth opportunities that attract the best people, the wisest physicians, the cleverest ex-military, the most civic minded outplaced employees, the most sophisticated civil libertarians, and the most idealistic recent graduates to psychiatry careers.
Leadership that radiates the national importance and prestige of such service will not only draw talent that in turn infuses creativity and results, and enhances community mental health and public safety. It will also eliminate stigma of mental illness and promote accessing mental health services through the more conventional channels. Those who see the best of Americans involved in mental health service provision will be drawn to it. Mental health leadership has to create conditions that inspire people to develop and dedicate professional lives to treating the seriously mentally ill and those in mental health crisis. It can and must be done.
