A Baffled Look

The straight dope on mental health

Month: November, 2012

Outpatient Commitment

I looked into outpatient commitment – or “assisted outpatient treatment” (how’s that for a euphemism?). Forty-four states have outpatient commitment laws. Most of these laws require a person with a psychiatric diagnosis to be court ordered to accept outpatient treatment, including medication, for their illness. These laws vary from state to state, but usually require that the individual has a history of noncompliance with medication and multiple hospitalizations or poses a risk for violence against self or others.  If these individuals don’t comply they are forced into inpatient treatment, which usually includes medication. The websites I found overwhelmingly supported such laws. It’s supposed to be controversial, but I found only three sites opposed to it. I found two blogs by patients and a website by the New York branch of the ACLU. All the psychiatry websites I looked at supported outpatient commitment. That’s not surprising. Most of them seem to sincerely believe it helps & is in the patient’s best interests. Leading the pack of these psychiatrists is E. Fuller Torrey, MD who founded the Treatment Advocacy Center. I’m sure Dr.Torrey means well, but he doesn’t consider the patients’ point of view. He advocates for the families of the mentally ill. No one seems to be listening to the patients.

Everyone responds to medications differently & the medications often have intolerable side effects. There seems to be a consensus that the medications – particularly antipsychotics – will magically work. Some people don’t respond to medications. What works for one patient may not work for another. And antipsychotics often make the negative symptoms of schizophrenia, such as flat affect and lack of motivation, worse.

Most of the mentally ill people I’ve met know they’re sick. Only a small minority don’t have insight into their condition. It’s tragic, but the Treatment Advocacy Center focuses on the very few mentally ill people who don’t know they’re sick.  Dr. Torrey and other psychiatrists who advocate for outpatient commitment increase stigma against the mentally ill. It encourages people to fear the mentally ill. These psychiatrists focus on the very few patients who are violent and not the majority who are no more dangerous than the general population.

I read John McManamy’s blog about forced outpatient treatment & it was very informative. His argument is that if the medications worked better and had fewer side effects, then the patients would take them. But most drug companies have no incentive to develop better medications because they’re making a ton of money from the drugs available now. Some researchers are looking into nicotine as a treatment. Many people with schizophrenia smoke because it helps them think better. Hopefully someday medications will be developed that will help people with psychotic disorders think better as well as take away their delusions and hallucinations.

There are already inpatient commitment laws. People who don’t meet those criteria shouldn’t be forced into treatment. I’m not against inpatient commitment for persons who pose a threat to themselves or others, but if they don’t meet those criteria then they should be allowed to make their own choices regarding treatment. They have a right to be crazy.

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http://www.mcmanweb.com/foced_meds.html

http://www.treatmentadvocacycenter.org

 

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College Counseling???

When I was getting my BA, I was allowed to go to student counseling services. In fact, they saved my life because they saw that I was seriously ill & sent me to be evaluated at a hospital. That’s when I got diagnosed with bipolar disorder. My shitty student insurance wouldn’t pay for therapy, but that was ok because I could still go to student counseling. When I got to grad school, however, I couldn’t see a counselor at my school because they no longer served students w/ psychiatric histories. They told me they provided referrals for therapists in the community. My university has a community counseling clinic for the general public, but they won’t see students. The local mental health community provider in my city doesn’t offer individual counseling either so if you’re mentally ill and taking classes at my university and need help, you’re screwed. Talk about people who need the most help getting left behind. It makes my blood boil.

State colleges and universities are seeing more and more students with serious mental health conditions. That may be because psychotropic medications have improved these students’ functioning. Many college counseling services have to limit services because of state budget deficits. Even if students qualify for Medicaid, few therapists accept Medicaid. Community mental health providers are strapped too much to offer counseling because of budget deficits. And many students are not state residents so they don’t qualify for Medicaid benefits or help from local community mental health providers.

According to The New England Journal of Medicine (July 12, 2007), “national surveys show that nearly half of the students who visit counseling centers are coping with serious mental illness, more than double the rate a decade ago. More students take psychiatric medication, and there are more emergencies requiring immediate action.”

College mental health centers’ staffs haven’t grown alongside with student enrollment. Some colleges have triage units to help students in crisis, but others have long waiting lists and limit the amount of therapy sessions for students. Many student counseling centers don’t provide follow-up care for students who have been hospitalized.

The laws that protect a student’s right to privacy are confusing. The Family Educational Rights and Privacy Act (FERPA), passed in 1974, is a college confidentiality law that is often misinterpreted. Faculties often interpret it as prohibiting the sharing of information about a student to others. Many college faculties don’t understand that that the law was not intended to prevent communication between deans & other faculty about academic records and behavior in class. College counseling clinics also fear that sharing about a student in crisis will violate the Health Insurance Portability and Accountability Act (HIPAA), even if the student is a danger to self or others.

I hope colleges can refer students to therapists who have a sliding scale for services. Many students are too embarrassed to call their parents and ask for help paying for a therapist. Other than that, I have no suggestions. I’m stumped.

http://minnesota.publicradio.org/display/web/2011/01/18/college-students-mental-health/

http://www.ulifeline.org/

http://www.psychiatrictimes.com/display/article/10168/1430329

http://www.nejm.org/doi/full/10.1056/NEJMp078096

http://www.nytimes.com/2010/12/20/health/20campus.html?pagewanted=all

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3107991/

http://www.youtube.com/watch?v=I9xSzaNuwOI

 

Consumer or Survivor? Part 5

The History and Fragmentation of the Mental Health Consumer and Psychiatric Survivor Movements

Last week I explored the split between the psychiatric survivor and mental health consumer movements. The consumers gained more recognition because they were less confrontational. The rise of the National Alliance on Mental Illness (NAMI) developed tactics on lobbying for mental health funding and research.

During the 1990s the survivors’ faction experienced resurgence partly because of developments of the internet and partly because of the sudden emphasis on biochemical and molecular research findings regarding mental disorders. L. J. Morrison (2005) states that congress declared that the 1990s were the “decade of the brain.” This “decade of the brain” emphasized biochemical and molecular solutions to mental illness and brought the radical survivors’ movement back into the picture (p.90). The Surgeon General’s Report in 1999 detailed the need for scientifically based treatment, the need for providing accurate knowledge to mental health consumers and the need for reducing barriers to treatment (p.90). Morrison goes on to explain that these recommendations may seem harmless enough, but their goals of treatment adherence and the expansion of pharmacological treatments caused a flood of objections from the survivors’ movement. Another survivor objection was NAMI’s efforts to introduce the Program for Assertive Community Treatment (PACT) model that allowed for forced outpatient treatment (p. 90). It was seen as a threat to freedom and human rights. Survivor activists teamed up with libertarians and scientologists to fight NAMI. The extremist Support Coalition International had over one hundred member groups. Morrison reveals that the Support Coalition International group developed a strong alliance with global human rights movements and gained consulting NGO status in the United Nations (p.91).

NAMI, however, dominates the consumer voice in mental health public policy because, as Morrison correctly points out, unlike the more radical survivors’ faction, NAMI was a strong national organization with many local chapters. They have more fidelity to national mandates (p.149). NAMI also had Dr. E. Fuller Torrey, a psychiatrist who believed passionately in the right to get well.

The radical faction of the movement has done little since the 1970s compared to what NAMI has done since the 1980s. NAMI’s website details a plan of attack and gains made in several areas of mental health social policy. For example, there is a page on their website that reports the passage of the Mentally Ill Offender Treatment and Crime Reduction Act of 2004 in the House (NAMI, 2006). The web page describes how NAMI worked with Congressmen and staffers. It is basically a jail diversion bill. Jail diversion is another program that the survivors’ faction dislikes because it involves forced treatment. NAMI also supported full insurance parity. This is another difference between NAMI and the survivors’ faction. The survivors believed it was another avenue towards forced treatment. Another item on the NAMI website is the 2007 HUD budget. NAMI teamed up with other disabilities organizations to make sure no funding for new Section 811 tenant-based rental assistance be included in the bill because HUD had failed to ensure that housing agencies were actually targeting rental assistance to persons with severe disabilities. It was not included in the bill (NAMI, 2006).

Although both factions have had a voice in U.S. mental health social policy, it is difficult to see what NAMI and the more extreme wing of the psychiatric survivors have in common. It would appear the only thing they share is self-determination. Both factions see what they do as human rights and see the other as harmful. The fragmentation between these movements is not likely to change any time soon.

References

Morrison, L.J. (2005). Talking Back to Psychiatry: The Psychiatric Consumer/Survivor.Ex-Patient Movement. New York: Routledge, Taylor & Francis Group.

National Alliance on Mental Illness. (2006). Policy Topics. Retrieved November 3, 2006, from http://www.nami.org/Template.cfm?Section=Issue_Spotlights

Consumer or Survivor? Part 4

The History and Fragmentation of the Mental Health Consumer and Psychiatric Survivor Movements

 

In the previous three weeks, I’ve covered some of the history of mental health policy in the US from colonial times to the birth of both the mental health consumer and psychiatric survivor movements during the late 1960s and early 1970s.

The 1980s brought legitimacy and some funding. These two developments brought about a split in the mental health consumer and the psychiatric survivor movements. L. J. Morrison (2005) addresses the split at length. She states that, “Two streams could be identified into the mid-1980s, corresponding to those who sought funding and developed self-help groups and the more radical faction that resisted co-optation” (p.80). Morrison states that budget conscious lawmakers saw self-help and peer groups as an inexpensive way to use mental health funding (p.80). The self-help movement was spawned by Judi Chamberlin’s 1978 book, On Our Own, which as a mental health consumer, she advocated for control over one’s own therapeutic fate. Family members of the mentally ill, patients, and ex-patients began to be asked to participate on local and state boards and committees. They had to behave appropriately, however, to be included, which meant the more confrontational tactics had to be abandoned in order to participate. This did not sit well with the more radical survivors’ faction of the movements. Morrison sums it up, “Unfortunately, finding a seat at the table and gaining recognition from the mental health establishment resulted in a major schism in the movement” (p.82). The more mainstream consumers’ faction won the most recognition. According to Morrison the radical survivors’ faction was ignored, while the mainstream consumers’ faction gained recognition. One of the beneficiaries of the federally-funded mainstream movement was the National Mental Health Consumers’ Self-Help Clearinghouse, which was founded by Joseph Rogers. Rogers was one of the most contentious figures of the split over power and co-optation (p.84). He advocates for the elimination of forced treatment and that choice is essential in recovery from mental illness, but is not opposed to the elimination of the institution of psychiatry (mhasp.org, 1999). Both the survivors’ faction and consumers’ movement object to his agenda because of his stand on these issues.

Another matter that did not make the radicals happy was the creation of the National Alliance on Mental Illness (NAMI) in 1979. NAMI lobbied for more funding and better psychiatric treatment. Their lobbying efforts greatly influenced NIMH funding for research on mental illness. They were able to achieve this in part because the prominent psychiatrist E. Fuller Torrey gave NAMI good advice on how to influence social policy. Morrison claims that Torrey helped NAMI by making the following suggestions: put NAMI representatives on city, county, and state mental health boards and advisory committees and have NAMI representatives become savvy with county and state mental health budgets by learning where the money was going (p.86). The main reason radicals did not like NAMI was because NAMI advocated for the forced community treatment programs (p.87).

Next week I’ll cover the 1990s, the “Decade of the Brain” and more about the National Alliance on Mental illness.

 

Reference

Morrison, L.J. (2005). Talking Back to Psychiatry: The Psychiatric Consumer/Survivor.Ex-Patient Movement. New York: Routledge, Taylor & Francis Group.

National Mental Health Consumers’ Self-Help Clearinghouse, (1999).. Retrieved November 3, 2012, from http://www.mhself.org/pubs/view.php?publication_id=1

 

Consumer or Survivor? Part 3

The History and Fragmentation of the Mental Health Consumer and Psychiatric Survivor Movements

The discovery of Thorazine as a treatment for schizophrenia and the National Mental Health Act of 1946 shifted care for the mentally ill to communities. Deinstitutionalization also continued to occur because former psychiatric patients worked to change commitment laws.  Precursors to the 1970s psychiatric survivor and mental health consumer movements are the actions of Elizabeth Packard and Clifford Beers during the institutionalization era. Linda J. Morrison (2005), in her book Talking Back to Psychiatry: The Psychiatric Consumer/Survivor/Ex-Patient Movement, describes the contributions of both Packard and Beers as both a call for legal reform in order to protect people from frivolous and unjust incarceration and the promotion of the value of support (p.65). According to Morrison, Packard’s focus was on the protections of rights and on abusive conditions of hospital confinement (p.63). Elizabeth Packard campaigned for the passage of laws that would protect a person’s right not to be classified as insane and submitted to abusive conditions without supporting evidence (p.64). These efforts resulted in legislative changes. Clifford Beers wrote A Mind That Found Itself, which documented institutional life. He called attention to inhumane conditions in asylums. Morrison asserts that he “campaigned for the recognition of mental illness as an illness that deserves humane treatment” (p.64). She states that Beers inspired the mental hygiene movement which today is represented by the National Mental Health Association (p.64). Morrison points out that even though both Packard and Beers were institutionalized as mental patients, they were privileged and they did not try to organize their fellow patients (p.66). She continues to make the distinction that Packard’s position may be a precursor to the psychiatric survivors’ movement and that Beers’ position is the precursor to the mental health consumers’ movement (p.66).

The beginning of the survivors’ movement was characterized by increased awareness of human rights abuses in psychiatric facilities, psychiatric treatment as a form of social control and the oppression of the psychiatric facilities to both workers and patients. Ex-patients from state mental hospitals began to seek out and attract lawyers to protect their rights. Involuntary commitment laws were challenged. These laws were successful in challenging previous federal and state statutes. In the 1960s and 1970s, several landmark rulings that restricted involuntary commitment were passed. In 1969, the California legislature passed the Lanterman-Petris-Short Act, which discouraged commitment and long periods of confinement. In August 1972 the influential Madness Network News began to be published by patients, mental health workers, and lawyers. Morrison states that knowledge about the rights and treatments for the mentally ill were exposed to the public (p.67). Dissident psychiatrists Thomas Szasz and R.D. Laing were often featured in the magazine. These psychiatrists portrayed madness not as an illness, but a different state of mind that challenged the sane community (Tomes, 2006, para.13). The survivors’ movement of the 1970s was inspired by other radical movements of that time. Both the consumer and survivor movements had a decent amount of support because of the mood of the times. Psychiatric survivors had good reasons to challenge the commitment laws. A lot of abuse occurred in asylums. They did not, however, support treatment in the community.

 

References

Tomes, N. (2006). The Patient As A Policy Factor: A Historical Case Study Of The Consumer/Survivor Movement In Mental Health. Health Affairs, 25, no.3, 720-729. Retrieved October 27, 2006, from Lexus Nexus Academic database.

Morrison, L.J. (2005). Talking Back to Psychiatry: The Psychiatric Consumer/Survivor.Ex-Patient Movement. New York: Routledge, Taylor & Francis Group.