The Cost Of Not Caring

There are rich stories of human suffering all around us couched in terms of financial crisis – stories we encounter in our news media, in the streets and even in our own families.

Nevertheless things are getting worse all the time and I have been in the middle of the battle on the same losing side as the mental health patients.

I have been in the middle of mass human suffering which nobody seems to have the power to alleviate.  For many years, as the situation worsens, I have done what I could.  I have been on every front of the battle known to me and accessible to me – in community mental health centers, the VA, state prisons and private, for-profit, insurance-driven treatment centers.

Sometimes the best service I can offer is not the pills.  It is all too often simply listening, and trying to come up with some practical ideas to help people navigate a fairly inhuman system.

I was still in Wichita, Kansas and still a resident training in psychiatry when I started writing a weekly question-and-answer newspaper column for the Wichita Eagle (the largest daily newspaper in the state).  I started tackling the stigma of mental illness early on.

I asked why the salt-of-the-earth folks of Kansas would often bring home-baked goods, like a pie (I love pie) to a next door neighbor who was, say, laid up with a broken leg, while no such goodies were generally proffered to the person who had recently been released from the psychiatric unit?

Not one person ever wrote to me at the newspaper to respond to that one, but I think I know the answer, and the answer is mostly “fear.”

Some of it is fear of the mentally ill individually.  This generally encompasses the fear of violence, as violent situations involving the mentally ill are generally those reported in the mass media.

The most prominent in the media is violence in and around schools, mostly done by young people within these schools – shootings, knifings, rapes and bullying.  Just check today’s headlines because I can’t keep up with reporting them all.

In most cases, the first conclusion people jump toward is a mentally-ill perpetrator.

Unfortunately – too many times – that is a correct assumption.

No matter how you slice it, the percentages of the mentally ill who are violent is pretty small — certainly in at least the same order of magnitude as the percentage of the population in general who might become violent for various other reasons.

Things like recent divorce, recent unemployment, drug or alcohol intoxication, road rage, and being an abuse survivor are more likely than even the most severe and chronic mental illness to provoke violent reactions.  Nobody seems to be actively avoiding these segments of the population.

This truth is ignored.

I spent a lot of time working in prison-type facilities.  There was always one “yard,” one building, reserved for those who had psychiatric illness.  The great majority of those who are inside prison do not have any kind of psychiatric history or current illness.

I did admittedly meet plenty of inmates who wanted to be perceived as having mental illness problems, since this meant “easy time” on the psychiatric yard, but that is another issue.

Part of the failure to befriend and socially accept the mentally ill seems to come from free-floating xenophobia.

I remember reviewing results of epidemiological “catchment area” studies on mental illness.  I have been looking at this sort of thing for a long time.

This kind of study takes people from the population at large and looks to see how many of them have psychiatric symptoms.  The figures for people at large usually come to 80 or 90 percent of the population having at least one psychiatric symptom.

You know people like this.  They are obviously not body-flinging themselves at psychiatrists.  People hate the idea of seeing psychiatrists for a lot of reasons, including “labeling” as being “crazy,” even to themselves and their families.

People make an awful lot of decisions emotionally, without carrying out the logic of data and reflection upon same.  Moreover, people never seem to take history into account, even when they are making decisions that are directly relevant to it.

Dorothea Dix was a wonderful crusader for the mentally ill.  She is generally considered responsible for the humane crusade in favor of the establishment of state hospitals to promote more humane ways of treating the mentally ill.

As a native of the Boston area, I will never forget the first time I heard the name of this other (earlier-civil war time) girl from Boston.

I was involved in “on the job training in psychiatry” at Fort Bragg, a Captain in the U.S. Army Medical Corps, pointing out some problems with the inpatient unit to the medical command.  I thought I was fairly temperate, but he told me nobody had taken up the cause of the mentally ill so emotionally since Dorothea Dix had come through town on a lecture tour.

Of course I went to the library to look her up in the encyclopedia right afterwards.

She was anti-slavery, of course.

I think that every time there has been a major effort to ameliorate human rights, the rights of the mentally ill are the subject of champions.

Like the crusade by Philippe Pinel at the time of the French revolution.

Or Benjamin Rush, who signed the U.S. Declaration of Independence. The ones yelling “we are part of an inhumane system” are no longer physicians, like these 18th century heroes of mine

Most of the arguments in the U.S.A. Today piece linked above are made on financial cost — not human suffering type cost — while the humanitarian arguments come from testimonials by mentally ill and families.

Congressman Tim Murphy, (R-Pa.) president and CEO, Mental Health America is the man cited in the third paragraph of the U.S.A. Today piece.  He is a former child psychologist who is now spearheading some kind of G.O.P. initiative that I never heard of until now.  Now I am no politico, but this tough stuff for me to understand.

I am old enough that I have learned a lot just by surviving and seeing what happens.

I will admit that I think of closing California’s state mental hospitals as a Reagan administration decision, made basically to cut costs.  That decision is “now widely regarded as a major failure.” Oh, the blame has been diffused among many, including even psychiatrists themselves.

Believe me, physicians in general and psychiatrists in particular are simply not very politically savvy, and wield very little control over their own fates.  Sure, there was plenty wrong with the old state hospitals (like some people who never belonged there happened to be inside them) but the same can be said of our over-crowded prisons.

It does not seem to me, even in retrospect looking at an essentially pre-internet phenomenon, that anybody did a thorough enough study of what would happen when these people hit the streets.

Like many purely-political decisions, it was a knee-jerk reaction to curry the votes of fiscal conservatives who would vote to save money – no matter what the cost – and to appeal to those who think psychiatry is the biggest boondoggle since the Ponzi Scheme was invented.

Curiously enough, the landscape of “regular” inpatient psychiatric care has changed also.

There are perilously few beds for people whom one would expect to need such care.  For instance, such beds — where they exist at all — seem to be reserved for those who need to be “5150-ed” — that is, hospitalized because they seem to have the will and intent and (maybe even) the means to cause real harm to themselves and to other folks, and therefore need to be contained for legal purposes.

In other words – involuntary commitment.

Nobody mentioned treatment, perilously little of which seems to be going on in these contexts.

I have seen many patients who have been in these units.  They generally tell me they have been scared into “shutting up” and “taking the damned pills” so they “do not have to go through that again.”  I have been told that insurance companies no longer pay for “voluntary” hospitalizations,  and like to monitor how someone reacts to new or different medications.

Often there is nobody in the home competent to do this sort of thing.  As an out-patient psychiatrist, I end up, usually, with vague instructions to use private hospitals and private insurance — which usually do not work.

I have often dispatched lower level staff  — who are either overstretched or in some cases, just plain disinterested — to help me figure out how relatively inarticulate patients live their everyday lives.  Sometimes they are on a neighbor’s couch or in the gutter with no hopes of eligibility for any kind of known assistance (or shelter), and are ashamed to tell me.

What they do, instead, is complain to me liberally about other psychiatrists being distant and unfeeling.  Although my first impulse was to condemn such behavior (feelings which I would never tell a patient about, anyway) I have since realized that the only way most psychiatrists can survive emotionally is to retreat into the (almost automated) pill-pushing role that American society has prescribed for them.

I think this is because their lengthy education has basically priced them out of the market for any of the other services for which they have been trained.

Again, without any serious studies of outcome, people generally get the “psychotherapeutic” or “touchy-feely” part of their care from lower-level, poorly trained “team members” rather than degreed professionals.  I’ve been in government institutions (county and state) that use peer-counselors – also known as “former patients.”

Wow – what a way to save money!

A psychiatrist cannot often have time or resources to offer empathy, let alone any kind of solution, for the grinding open-wound pain of the indigent who must be seen and dealt with on a daily basis.  We are often at the mercy of an over-booked schedule, determined by administrative people who are more interested in churning a high-number of people through the system so as to collect a payment for each person “seen.”  It is not uncommon for a doctor to only be allowed a few minutes with each patient – which presents a challenge to a dedicated care-giver.

Whether these people are actually helped is not the primary concern.

Psychiatrists can only become emotionally battered.

There are always good people in every situation – and I’ve met some great and caring people in my travels — but they tend to move on and the drones and bureaucrats stay put.

Me, as I look back, I think my entire family, both immediate and extended, either was a psychiatric patient or should have been.  Thus for this reason, I have very informal, often even comfortable family-like relationships with patients — and this usually works fairly well.

Still, people do not do things for the reason they say they do.  We cut sweetheart deals to let corporations profit, we spend money on wars, and we seem to have created a sad underbelly of society where people are ill, and cannot afford treatment for their illness.

Drug companies grow, with the marketing of inexpensive and easy-to-market drugs that often — particularly in psychiatry — seem to me to be more expensive with no more (and probably fewer ) benefit than what has come before.

A review of psychotropic sales and use could be found in many places, such as this documentary film, free to view on YouTube.

As for the spending money on wars since the 21^st century commenced — I am not at all convinced we are giving enough quality treatment to the veterans we already have.

Where does all this come from?

Hubris, I think.

The United States seems to somehow believe that we are the police of the world, and uses this belief to put a lot of money into wars and make a lot of money for people who appear to be corporate giants, but definitely are NOT the mentally ill, or other people dying from a lack of healthcare.

Where the heck does this idea come from?

Our earliest well-documented enunciation of said idea was the Monroe Doctrine, which James Monroe seems to have cleverly hidden in his 1823 annual message to congress.

Basically, this is the idea is that other European countries, with “puppet” monarchs and designs upon those lovely U.S. states ever so rich in natural resources should stay in Europe and leave the  U.S. alone.

Early 19th century?  I am not sure who was listening or how closely, but that was when we went into a period of expansion all over the North American Continent (south of the Canadian border.)  Talk about the pot calling the kettle “black.”

We called it “Manifest Destiny,” according to a prominent journalist in 1845.  We took over the whole continent to the West Coast of America.

We decimated Native American entities that considered themselves “sovereign.”

We kicked out the Mexicans, annexing Texas — and not stopping until we had conquered about half of their land and made it our own.

Oy!

That is “Hubris!”

I thought for a while, based on schoolbooks, we had done this mainly to acquire the lovely, unobstructed ocean view you could get from Malibu, or even Long Beach.

This conduct caused us a lot of problems.

Sometimes, in the fiery eyes of Mexican immigrants, I am convinced I see a sense of proud entitlement to the land that first was theirs.

But wait, there’s more.

Numerous political, economic, and social consequences; basically really big growth and somehow, this was an expression of some kind of white supremacist and (dare I say it) Christian ideology.

Double Oy!

If you doubt for a moment that the United States is a Christian Theocracy, let me share some observations gleaned from my native Jewish vantage point.

What are termed our American-core ideas have deep roots. I do not see them getting changed easily.

There was a chart on the door of my sixth grade classroom that showed the influence over time of various countries, and ended with the color representing the U.S. taking most of the thickness of the diagram, clearly being the most influential country in the world.

We aren’t the top guys right now, but we could be.

Changing beliefs is not for sissies.

Speaking as both a veteran of the US Army and a medical doctor, I believe we should be spending money taking care of our own instead of supporting military expansion and excursions.

Then, I believe, we can be “number one.”

A good market would understand how to redefine number one.

The USA is “We The People” – not a political party, not a corporation, not a military organization.

Somewhere, along the line, we will have to start thinking about the welfare of humans – our citizens who are guaranteed rights — something we have done preciously little of late.