Treatment Perspectives

Dr. Alexander S. Young, an expert on the quality and efficiency of mental health services, said that the United States spends about 14 per cent of its gross national product - more than $1 trillion dollars - on health care, with outcomes that fare poorly when compared with the rest of the industrialized world.

He chaired a panel on Treatment Perspectives as part of a symposium on Mental Health & Public Policy Jan. 12 at UC Berkeley and UCLA, linked by video teleconferencing.

Dr. Young recommended we remake our health care delivery system because outcomes rank poorly in comparison with the rest of the industrialized world. To meet these challenges, he said, we will have to overhaul managed care which he said has provided a way to cut costs but has done little to improve the overall quality of services.

Our mentally ill face inadequate treatment or lack of treatment, suffer with addiction, face discrimination and live on the streets in a nation with the highest per capita spending on health care in the world, he and other panel members concluded.

Blaming current polices for creating major social costs without meeting the needs of the mentally ill, the panelists called for sweeping changes because outcomes rank so poorly.

Dr. Young, M.D., M.S.H.S., is Director of the Mental Illness Research, Education and Clinical Center Health Service Unit, Veterans Healthcare Network of Southern California and Nevada, Assistant Professor at the UCLA Department of Psychiatry and Consultant at RAND.

Panel members included Barbara E. Havassy, Ph.D., Professor of Psychiatry and Director of the Treatment Outcome Group in the Department of Psychiatry, UCSF; Dave Hosseini, Executive Director, Consumer Self Help, Sacramento; Steven P. Segal, Ph.D., Professor and Director, Mental Health and Social Welfare Research Group, School of Social Welfare, U.C. Berkeley; and Harold E. Shabo, J.D., Mental Health Supervising Judge, Los Angeles Superior Court.

Even with the high rate of health care spending, Dr. Young said, many with mental illnesses go untreated and end up in jails or prisons as a result. He said changes will take the cooperation of patients, families and other care givers, providers, and society at large.

Dr. Young urged efforts to improve clinicians' competencies so they can understand and provide new approaches and implement disease management by changing the division of labor and responsibilities. A clearer focus on self-help and peer support with a recovery model which gives an expectation of results would meet these needs and would empower consumers, while giving them hope, he said.

Dr. Young laid out a treatment formula built around appropriate medication, family and care giver involvement coupled with assertive treatment targeted for patient rehabilitation. He said this is a wonderful time to be working in the area because of recent advances, but warned that stigma remains a major barrier to treatment.

He noted that two-thirds of those with anxiety and depression receive no effective care. He said the frequency with which people receive neither medication nor counseling was approximately 63 per cent for whites, 81 for blacks and 76 for Hispanics. Similar disparities exist by age, with the young and the elderly being most neglected.

Dr. Havassy said no link exists between programs for drug abuse and for mental illness even though 51 per cent of drug and alcohol treatment program clients are mentally ill and a high percentage of those in treatment programs for the mentally ill are substance abusers.

Because each program assumes the priority of its focus, she said, patients who are mentally ill and drug abusers don't receive proper care. Her research has focused upon substance abuse by the mentally ill.

Dr. Havassy has studied the extent of drug involvement of both groups, and noted that there are few diagnostic differences between participants in each group. She said most striking overall is the prevalence of mental health disorders in the drug treatment program.

Judge Shabo, providing perspective from the bench, supported AB 1421 because it would give judges the power to provide for supervised outpatient treatment that could reduce the number of the mentally ill who are imprisoned.

Mr. Hosseini, however, called AB 1421 ill- advised, urging instead a rehabilitative approach with treatment in the community to make the services more humane.

He said his greatest pride was as a member of the California Network of Mental Health Clients, said that it is imperative that policy makers listen to those who have firsthand knowledge--the patient and the client community.

Citing the motto, "Nothing About Us Without Us," he urged that all programs include from the start those who have the most to gain or lose from policy development, the clients.

Mr. Hosseini said the community and the social practitioners in mental health in California "for the last three years...have been a community under siege" because of AB1421. He called AB1421 legislation that would turn back the clock on mental health care and turn away from the best principles and the practices of the last 30 years.

Countering this view, Judge Shabo said AB 1421 would give judges the power to provide for supervised outpatient treatment that could reduce the number of the mentally ill who are imprisoned. He urged those who oppose it to read it again and to learn of its positive features.

Bringing to bear the perspective of the bench, Judge Shabo said he was struck by how many mentally ill persons he encountered who came into the criminal justice system, raising the question of why they were there and why they had not received needed care that would have kept them out.

Mr. Hosseini said that rather than impose programs he recommended that the clients be offered choice, be given an opportunity to demonstrate recovery, and treated with an emphasis on respect, dignity and self worth. To avoid the downward spiral into homelessness and despair, he posed this dictum: "First do no harm."

He urged a fight against stigma, which he labeled plain and simple discrimination, and for the design of policies and programs as an antidote to stigma.

Mr. Hosseini called for "kind of love, an affirmative demonstration of caring: acceptance, concern...and hope." This, he said, requires "listening and hearing the hopes, fears, and aspirations of clients.

"How do you craft love in public policy: Isn't idealism and hope the reason we share an interest in this topic? We need to remember that hope is an important ingredient in any remedies.... Come with us and move forward together toward a new day of hope, empowerment and true recovery."

Dr. Segal of the School of Social Welfare at Berkeley reinforced Mr. Hossein's views and Judge Shabo's concerns. He said that "the mentally ill are extremely vulnerable to adverse social context changes and treatment is not robust, its positive contributions are easily overwhelmed by negative circumstances."

His research has focused upon mental health services related to long-term community and residential care, civil commitment, the assessment of dangerousness and quality of psychiatric emergency care in general hospital psychiatric emergency rooms and consumer roles in service provision.

Dr. Segal blamed urban renewal and housing policies for the growth of homelessness among the mentally ill. He said "consigning people with mental illness to treatment within the homeless services system is unconscionable. Homelessness is a breeding ground for biopsychosocial ills. It places people with mental illness at risk of increased involvement with substance abuse, tuberculosis, AIDS, and the criminal justice system.

"The objective of treatment is to provide quality care, the definition of which lies with the stakeholders in the interaction.

"The mental health professional's perspective emphasizes technical quality in therapeutic interventions; the patient's perspective, personal involvement in the decision process regarding their own care; and the administrative perspective, efficiency in service delivery."

Dr. Segal outlines a five-point policy program:
1. Develop a full spectrum of State sponsored housing supports including independent living, supported housing, supervised housing and group care facilities for the seriously mentally ill. These facilities need to include true alternatives to hospitalization (as opposed to rented rooms at single room occupancy hotels) as well as permanent supported housing arrangements.
2. Stop using hospital retention as a negative indicator, for many it is a necessary life saver.
3. Support efforts to give the patient/client an active role in decisions about their own care both within professional and through self help programs. When at all possible help persons retain responsibility for themselves.
4. Use coercive interventions with caution and only after underwriting efforts that protect the seriously mentally ill against structural abuses.
5. Stop using the grant mechanism as a funding means. We know an integrated system of care works. Fund the system, not model programs that disappear when they are no longer sexy.
6. Above all Dr. Segal emphasized the need to add stability and adequate provision to our mental health services system, protecting caregivers as well as people with mental illness and avoiding the practice of narrowly defining medical necessity to exclude the social consequences of the disorder.

Judge Shabo presented two tapes, the first made in 1991 by NBC depicted homelessness and conditions within the Los Angeles County Jail for the mentally disordered. He noted that although there has been some improvement at the jail, the problems remain serious and are representative of conditions faced throughout the United States. The tape pointed out that the L.A. County Jail is the largest mental institution in the United States, which remains true to this day.

The second tape, from the Lehrer Report depicted the lack of treatment for mentally ill offenders in the California Prison system. Judge Shabo said the tape depicts the poor level of mental health care and treatment in prisons throughout the United States and was made at the time a federal judge in San Francisco ordered upgraded services for prison inmates. Since that time the care has improved, he said, but the system has a long way to go.

Judge Shabo said it is imperative to better train judges, lawyers, probation, parole, and correctional personnel. This, he said, is because they do not understand the manifestations of the mentally ill, there is too much territoriality and they only grudgingly accept those in jail or on parole.

A second major requirement, he said, is to establish mental health courts in California that will give the judge the power to order agencies to provide services as needed and as promised.

A third imperative, he said, is to increase training of law enforcement officials to recognize the mentally ill, especially when they do not conform to rules, often because they cannot.

Judge Shabo called for comprehensive wrap around services tailored to the needs of the offender, which he said would pay off by reducing the number of mentally ill jailed and allow out patient care.

AB1421 would provide for assisted outpatient treatment and for patient input into discharge planning, Judge Shabo said. He said it would give the courts the authority both to ensure care and to monitor the quality of that care that could prevent the incarceration of the mentally ill in jails and prisons as portrayed in the two film clips he used in his presentation.