Mental Health Inc

by Art Levine

  The best of the Los Angeles County’s Department of Mental Health programs, as at The Village, can have a powerful and uplifting impact. But since there is little long-term follow-up and no commitment to helping people obtain competitive jobs, even the most dedicated staff can’t help the people they serve live truly independent lives. That reality is barely masked by the department’s co-option of the emerging mental health consumer movement under the guise of offering volunteer opportunities in clinics and awards ceremonies, which have become a form of extended paternalism that traps people inside the mental health system for life.

  “We’re treated like mascots,” says Brenda Jones, an early graduate of DMH-sponsored training programs and college-based counseling certificates who can’t get the sort of “supported employment” assistance available in Alameda County in California and about twenty other states. “They’re pimping us out for gift cards,” she says of the endless cycle of short-term volunteer jobs for “consumers.” The unemployment rate of people receiving services of various intensity at LA County clinics is close to 90 percent.

  As county officials concede, with a few exceptions, they don’t use the well-proven “supported employment” approach. “Los Angeles County is terrible,” says Dr. Robert Drake. “If you’re not helping people find independent, competitive jobs, you’re just blowing smoke about recovery.” As Keris Myrick, the director of consumer affairs for SAMHSA’s Center for Mental Health Services who manages her own schizoaffective disorder with medication, therapy and the life purpose offered by work, told me when I visited LA, “People can’t come into the system for treatment because people can’t get out, so there’s a logjam,” seen in long waiting times, overcrowded clinics and harried providers. “There’s a fear of letting them go because something bad will happen to them.” As a result, while those with life-threatening crises can usually get an emergency response, there are waiting lists for basic psychiatric care as long as ninety days at some clinics.

  The worldview of the consumer movement that’s supposed to improve treatment, promote alternatives to traditional psychiatry and remove stigma is not widely known outside of the world of mental health care. That has changed somewhat since it has been publicly smeared by critics such as Dr. E. Fuller Torrey as a motley array of crazies funded by SAMHSA taxpayer dollars at “Alternatives” conferences. But it grew out of a desire by “peer advocates” and mental health consumers for a greater say in the care they received. At the same time, there was a growing recognition by academic researchers that peer-to-peer counseling, drop-in centers, and peer-run respite centers as alternatives to visits to the ER were showing increasingly robust evidence that they improved clients’ well-being. At The Village, for instance, all the “Full Service Partnerships” include a “peer” with “lived experience,” and peer counselors play an increasingly important role in the most effective treatments for serious mental illness, including supported employment.

  Yet the value of peers and even the once-accepted goal of “recovery” as part of mainstream psychosocial programs are viewed with disdain by the incoming assistant HHS secretary overseeing SAMHSA, Dr. Elinore McCance-Katz, most recently the chief medical officer of Rhode Island’s mental health department and the former top medical officer at SAMHSA until 2015. In controversial 2016 articles in National Review and Psychiatric Times, she justly took the agency to task for downplaying evidence-based psychiatric services for the most severely mentally ill people in its recent grants to the states. But she also denounced all initiatives for developing a peer workforce as “trivializing” the devastation of untreated mental illness: “Peer support can be an important resource for some, but it is not the answer to the treatment needs of the seriously mentally ill,” she declared. In the articles that were thinly disguised job applications to Donald Trump, whose election she described as “an exciting turn of events for people afflicted with mental illness,” she ignored altogether the embrace by peers of the leading programs aiding severely mentally ill people developed by the nation’s pioneering mental health researchers, including Dr. Robert Drake.

  Peer counseling grew out of the mental health consumer movement that by the 1990s had begun to formally organize, echoing the South African disability movement’s motto: “Nothing About Us, Without Us.” Now, in Los Angeles County and most major mental health departments in the country, at federal agencies such as SAMHSA, and in advocacy groups such as NAMI and Mental Health America, there are peers and consumers in leadership and advisory roles. But that hasn’t translated, at least in LA County, to clients’ long-term recovery and independence.

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  FOR ALL OF THE ABUSES AND CORRUPTION IN THE NATION’S MENTAL health system, there are clear-cut solutions and reforms that could be implemented. They range from stopping the payments for off-label antipsychotic prescribing to incorporating proven treatment programs to cracking down on unregulated “troubled teen” facilities. But those answers have been known for years, even decades, and nothing’s been done about it.

  There could be a way out of this permanent state of inaction if the lesser-known groups, activists and experts who care deeply about these issues take it on themselves to recruit potential allies among the most influential national advocacy groups, while packaging shocking scandals they know about to win the attention of media outlets. Currently, there is simply no well-organized, powerful national lobbying or legal advocacy group in the country working to halt the dangerous, unproven practices that are so profitable, particularly the overdrugging of children, veterans and the elderly. Top AARP executives, for instance, won’t do so unless other experts and advocates figure out a way to shame them or recruit them into taking real action.

  On almost every issue raised in this book, there are passionate activists, survivors and experts. Relatively few, however, have the political, legal or media clout to have much impact.

  The challenges of fixing the VA and reducing veterans’ suicides are among the most intractable problems in mental health care. That’s due in no small part to the sharp ideological divides over reform; the sheer size of the VA system, with over 1,200 health-care facilities and 1.6 million veterans receiving specialized mental health treatments annually; and, perhaps most of all, the uniquely poisonous and, at some major VA centers, quasi-criminal leadership willing to cover up fraud and negligent patient care while retaliating against whistleblowers. A good starting point for change is the thoughtful VA Commission on Care report that called for broader patient choice through the private sector and more visionary leadership to promote better quality care and faster access. But it doesn’t go far enough, because it assumes on faith that all specialized mental health programs at VA facilities are always better than what’s in the private sector, and doesn’t provide a mechanism for systematic evaluations from outside evaluators of treatment quality that simply can’t be manipulated by VA staff.

  Fortunately, the chair of that commission, Nancy Schlichting, the CEO of the successful Henry Ford Health System of Detroit, has unique insights to offer the VA. Under her watch and with her then-chief of behavioral health care, Dr. C. Edward Coffey, they brought suicides down to zero for a patient population of at least 200,000 in the HMO for nearly three years in a row. Even today, their suicide rate of 20 per 100,000 mental health patients is 92 percent less than the national average. Their “Perfect Depression Care” initiative galvanized clinicians and incorporated well-known but rarely used prevention strategies, such as brief screening for depression by primary care providers that led to mental health referrals, and working with patients’ families to make sure there weren’t weapons at home. But they also encouraged a responsive staff approach of studying suicide tragedies to learn what went wrong, as opposed to downplaying or covering up failures—the hallmark of the VA system.

  In the context of the wide-ranging VA scandals, a major shake-up of top administrators at many VA facilities is needed. To make clear that accountability will be imposed on all managers, m
ore funding for agencies outside the VA to investigate wrongdoing is needed since its internal investigative agencies generally can’t be trusted. This includes dramatically increasing the staff of the independent federal Office of Special Counsel to investigate whistleblower complaints. Those complaints then can be used by Justice Department prosecutors experienced in health fraud and organized crime to build criminal cases on fraud, perjury and obstruction of justice charges against the most irresponsible administrators if firing proves too time-consuming. Marching several high-profile, bonus-collecting VA executives and their henchmen out of various regional VA hospitals in handcuffs could have a salutary effect. Whistleblowers’ hopes for such a crackdown, though, are unlikely to be realized with Shulkin as head of the VA.

  Even so, to speed these goals along, I have a few personnel suggestions to prod the new Secretary of the VA to fix the agency and change its culture. Hire Dr. C. Edward Coffey, currently the CEO and President of the prestigious Menninger Clinic, as under secretary of health with a special portfolio for suicide prevention; and appoint Joseph Beemster-boer, the chief of DOJ’s Health Care Fraud unit, either as a special prosecutor with a broad mandate to prosecute or force out rogue administrators, or as the Inspector General. These selections involve the traditional good cop/bad cop approach brought to transforming the VA.

  For both the VA and the nation’s mental health system, one of the thorniest problems is the division between drug treatment and mental health care, which puts both recovery and sanity at risk every day. About 50 percent of the most severely mentally ill people also have a substance abuse problem, while little over half of drug addicts have at least one serious mental illness. The solution is offering effective, personalized, integrated treatment by staff cross-trained in mental health and drug addiction, along with such strategies as “motivational interviewing” to spur change.

  The results are striking. Drake led a seven-year follow-up study of inner-city Connecticut residents with schizophrenia and substance abuse who were offered those services—and found that 70 percent later didn’t have psychiatric symptoms and over 60 percent were no longer substance abusers. Unfortunately, relatively few state regulators are now paying attention to whether these services are being delivered properly. That could change if an independent assessment system—co-developed by a colleague of Drake at Dartmouth, now at Stanford Medical School, Dr. Mark McGovern, as described in detail in the book Inside Rehab—was widely applied across VA and Medicaid programs, as it has been used in the past with select private and government-funded community treatment programs. For several years ending about 2012, there was hope that this could actually happen, because SAMHSA gave roughly fifteen states millions in grants to expand their drug addiction and mental health clinics’ capacity to offer quality cooccurring disorder services, largely through far better independent evaluation of programs followed by staff training. This, in turn, inspired more than thirty states overall to adopt in varying degrees these evaluation methods. Then SAMHSA pulled the plug on its incentives.

  McGovern’s assessment tools have been essential: Going by the names Dual Diagnosis Capability in Addiction Treatment (DDCAT) and Dual Diagnosis Capability in Mental Health Treatment (DD-CMHT), they’re used, respectively, for drug treatment and mental health centers. They measure everything from leadership to evidence-based treatments, and then are used to spur improvements.

  It takes only a one-day site visit to fully assess and write up any clinic. The reality, though, is that as few as one in ten mental health clinics—and 20 percent of addiction clinics—actually have the capacity to adequately offer these services despite their marketing claims, as he reported in 2014.

  Except for a relative handful of states, such as Washington, spending their own funds on it, McGovern’s smart method to promote quality dual-diagnosis care isn’t widely used anymore. “We had an opportunity to offer good care and save lives,” he says. “The human toll is immeasurable,” especially with opiate overdoses skyrocketing.

  But it seems likely that a lawsuit or new legislation are the only ways to force the VA to accept such independent evaluations in a way they couldn’t game—as they’ve done with all other rating systems.

  Virtually every major problem in the mental health system has a solution waiting to be implemented, but virtually no one in power wants to carry it out. At the national level, when it comes to off-label prescribing, some of the smartest thinking comes from groups such as the Lown Institute and its “Right Care” initiative that’s developing a community organizing approach to fighting overtreatment of all kinds, a model that’s already worked in the UK to bring down antipsychotic overmedication for the elderly. Lown shares a common goal in challenging overmedication with Georgetown University’s Pharmed-Out conferences and the “Selling Sickness” campaign, co-developed by Kim Witczak after her husband “Woody” killed himself at age thirty-seven, shortly after starting Zoloft. If they could enlist the Nader-founded Public Citizen Health Research Group to take on this issue with lawsuits, media assaults and grassroots activism, then perhaps the prospects for change in these deadly practices could improve. The Lown Institute’s campaign scheduled for the fall of 2017, a “Right Care Top Ten” that highlights five “Do’s” and “Don’ts” for different health arenas, including behavioral health care, is a promising start that could be amplified by an alliance with Public Citizen.

  For almost every reform that’s needed, there is an alliance that could be built to push it forward, anchored by a powerful advocacy group or well-connected community leaders. Judge Steven Leifman in Miami-Dade County constructed over the years a statewide coalition, including leading law enforcement officials that brought about the county’s innovative alternatives to jailing the mentally ill. Judge Ginger Lerner-Wren in Broward County, Florida, in 1997 pioneered the nation’s first mental health court, which routes mentally ill non-violent misdemeanor offenders into voluntary treatment overseen by the judge instead of into jail. She was backed by mental health advocates and court leaders prodded into action by a grand jury’s rebuke of the county jail for warehousing thousands of mentally ill inmates for minor crimes. Over three hundred mental health courts are in operation nationwide now, and when they work well, as a 2015 review of major studies in Pacific Standard magazine found, they reduce re-arrests and days in jail by nearly half.

  In a similar fashion, the opportunity to promote better, nondrugging, community-based alternatives to juvenile detention for children with emotional problems could become a higher priority issue when already influential reform groups add this goal to their agenda. New attention to the junior division of Incarceration Nation could be won, for example, if the Children’s Defense Fund (CDF) and its state chapters took stronger action on this front. (Its influential president, Marian Wright Edelman, has already spoken out against the overmedication of kids.) For instance, CDF could actively promote such well-documented alternative programs as multi-systemic therapy, which slashes re-arrest rates of troubled juveniles by as much as 90 percent, as I found in the SHIELDS program for low-income youth in LA. Their outreach workers did it through parent and child in-home counseling that strengthens the parent’s involvement in the child’s school, friendships and community. In addition, if CDF decided to square off against CMS on its pro kiddie-drugging policies, children’s health and even their lives could be preserved.

  Unfortunately, we can’t expect the leading national mental health advocacy groups to be agents of change in stopping dangerous practices. The NAMI and Mental Health America organizations receive 19 percent and roughly a third of their funding, respectively, from drug companies. NAMI, for instance, was an early champion of J&J’s TMAP program and has fought any efforts to restrict prescribing of antipsychotics. Neither group has taken a strong public stance against the overmedication of children, and leaders of both insist that drug industry funding hasn’t compromised their policy positions. Yet when I suggested to one organization’s local activist that the national
group take a stand against dangerous off-label prescribing that could change their image as being under the thumb of the drug industry, she replied, “We are under the thumb of the drug industry.”

  Laundry lists of proposed reforms, of course, don’t bring about change. The governing philosophy of those seeking to change our dangerous and ineffective mental health system could be lifted straight from the Hippocratic Oath: First, Do No Harm. And it should be amended to read: Second, Do What Works. Yet, sadly, the prospects for the wider use of innovative and effective programs are even bleaker now in the Trump era if indeed insurance coverage shrinks and Medicaid budgets are slashed.

  In looking over the landscape of reform, it almost always has come about because someone in power has been forced by a lawsuit, court order, media coverage or public protests to change. In medical care, paying people extra to do the right thing and refusing to pay for bad treatments can also have an impact. Changing the way we treat people with a serious mental illness should be considered a social justice issue that goes beyond just those affected by its devastating impact. And when change does occur, its effect can be profound.

  Robert Drake, for example, remembers one of the first mentally ill people he recruited to participate in a trial of supported employment. “He was a guy in a day treatment program and I was his doctor,” he says. “He just sat around, saying nothing, for years.” With his long-lasting schizophrenia, the patient was so moribund and quiet that Drake sent him for neuropsychological testing, which didn’t show any underlying physical disease. Then a colleague working in the supported employment program somehow recruited him and helped him find work. “I thought he was the last guy in the world who could get a job,” he says.