Let’s Talk About Treating The Mentally Ill

“Then the Lord said to Cain, “Where is your brother Abel?” “I don’t know,” he replied. “Am I my brother’s keeper?”… Genesis 4:9

There is a video going around of Congressman Joseph Kennedy III “making GOP lawyers admit that GOP repeal plan will cut off coverage to millions of Americans suffering from mental illness and substance abuse disorders”.  Incredible kudos for Mr. Kennedy… for doing his job.  Still, to my amazement, no other Senator or Representative seems to have noticed. This is typical of American culture and it breaks my heart.

There has always been a tendency among politicians to care least for those who don’t or can’t vote. There has always been a tendency among insurance companies to pay for as little as possible in covering care. This is how they keep costs lower (and profits up). There has always been a tendency to hide your crazy uncle or crazy aunt in their room, away from the rest of the world. None of this is new. The attempt to repeal the Affordable Care Act is just the most recent and severe form of atrocity against the mentally ill, and it must stop. Rendering the mentally ill in this country invisible and hopeless is wrong on so many levels that I can’t even begin to count.

The public process began under then-governor Ronald Reagan in California in 1967 under the Lanterman Petris Short Act, which was hailed as a vote for freedom for the mentally ill when it began closing down all of California’s state mental hospitals in favor of “community-based treatment” — mental health clinics, psychiatrists and the like. It was that, as no longer could people be “warehoused” away from the sunshine and civilization, families, etc. In typical Reagan style, it also had the added effect of cutting costs from the budget of the state. No longer would the state have to pay for upkeep of buildings, staff, and so on. The mentally ill could get their treatment without it. It was a win/win situation.  What no one counted on was that many of the families of these patients didn’t want them back. They were embarrassed by the craziness of their relatives already. Some had shipped their wives off to get rid of them permanently, using the system in place at the time. Most people had simply moved on with their lives and simply didn’t know how to have another person in their home.

The simple solution to this was homelessness. The state didn’t have to pay, and families didn’t have to deal with family member they couldn’t handle. Of course, the only people this didn’t work for were the long-term mentally ill, who were now “free” to be invisible and struggling with the challenges that daily life brought. They became “those bums who live in the park or under the bridge” — still not a part of society, but now no longer cared for either. Add to this the men coming back from Vietnam with PTSD and you had an ever expanding population of invisible homeless. Add to that the population of homeless vets who were addicted to opiates — shooting heroin or smoking opium — and there were more invisibles who needed help. With the war on drugs imposed by Nixon, the state took responsibilities for some of them in a different institution — prison.

Those addicted or mentally ill people who weren’t imprisoned began having families. Growing up with genes for mental illness, raised by either addicted or mentally ill parents pretty much guarantees  more mentally ill. The 12-Step movement of the 1980’s became a place where people could cope withe addictive part for nearly free and became a gateway into fuller mental health care with therapists and psychiatrists and the like.We began the age of Big Pharma as new drugs were developed to treat various illnesses  like schizophrenia or mood disorders. Psychiatrists moved toward this medical model and more patients could be seen/helped. Other types of therapists, MFCCs and MFTs and LICSWs could do the talk therapy part and mental health was becoming more common among insurance needs. Care seemed to get better and more available for most people who had short-term needs for therapy. “Medical neccessity” for treatment being the decision making tool here, when you were done with your 12 sessions, you were supposed to be “fixed”. With your meds you could stabilize what ailed you and you were good to go, according to the insurance companies.  They couldn’t be expected to treat people’s illnesses forever. They weren’t set up for that.

What that means is that if your problems lasted more than 12 weeks per year, you were pretty much out of luck with your average insurance company. The only way to get more than that was to get federal disability (a long, drawn out process) or state insurance which only certain doctors took and standards of care could be lower. Interns, for instance, can treat at an agency that takes state insurance.  At least we had a safety net… until we didn’t.

All those “entitlements” that the government and American citizens don’t want to pay for? Disability, welfare, food stamps, etc.? If you already can’t handle stress, and can’t get help to handle stress, wondering where your next meal or your rent is going to come from isn’t going to help. So, less money = more stress = more mental illness.

How do we handle it? We blame them for their poor choices, not ours. The problems with this logic is that some people are simply born predisposed to mental illness and with anything like an overwhelming life, they become mentally ill for life. In addition to that, sometimes things just happen: 9/11, for instance, happened. People got overwhelmed, and needed more therapy than 12 weeks and meds.

Because only bad people take drugs, (see “blame”, above) if people actually needed them, there was a problem. Poor people got theirs on the street, or grew it in their backyard.Many of them went to the alternative to the State Hospital we call “jail”. Rich people got theirs from their psychiatrists. The problem there? There was money to be made off of addictive meds, and Big Pharma reps weren’t telling anyone the truth about it. At first it was valium and xanax for anxiety. Later Oxycontin, which frankly should never have been on the market for general use, was given out like candy for pain. But they couldn’t be addicted (again, see blame, above) because they hadn’t made bad choices. they were only taking their meds as prescribed. When the doctors stopped giving them meds, those people (who couldn’t be addicts, but were)  ended up going to the same dealers for heroin. Enter the opioid crisis and laws to protect the “good people” who were suddenly addicts. Big Pharma had  made their money.

Because Big Pharma had made its money, Big Insurance didn’t want to pay for it. Between Obamacare and Ted Kennedy’s Mental Health Parity law, the government said they had to. So, many of my clients now come to me with $5,000 deductibles, because the insurance doesn’t want to pay, and wants to make something like a profit and they need revenue. Now, people pay for insurance and don’t get any coverage until they spend $5000 (on top of paying for their insurance in the first place! — a reasonable critique of Obamacare, but maybe a better critique of Big Insurance (or Big Pharma…?).  In this case, under Obamacare, fewer and fewer people actually get mental health care because their insurance won’t pay for it.

The only thing worse would be for nobody to have coverage. So that’s what repeal of the ACA means. Fewer and fewer people with mental illness can get treatment or afford their meds or both. Regarding the long-term mentally ill, we have closed down the State Hospitals and replaced them with jails — sometimes “for profit” jails, as though profits haven’t been the problem at any other step along this path.

This is what the situation is now, after all our government policies: We have homeless and jails where we used to have State Mental Hospitals, we have a society addicted to meds — either to cope with the stress of being poor or the privilege of having mental illness and being rich. Insurance is nearly unaffordable for the mentally ill, and thus, treatment is hard to come by. Big Pharma is taking its money and running because we can’t punish  corporations because they would get hurt.

Oh, and the one thing the mentally ill can get more easily? Guns. Congress, in all its collective wisdom, backed by this President, and driven by the NRA, has made it easier for the long-term disabled mentally ill to get guns by repealing common sense gun legislation. Apparently, guns are more important to freedom than mental health is. And tragedy with guns never happens to “good people”, right?

None of this seems to be working. So, what’s the solution?

1. First and foremost, and foremost, repealing The Affordable Care Act (aka “Obamacare) is not the answer.
2. Fixing Obamacare, if that’s possible, is a start.

The rest of it lies in the human heart.

1. We have to realize that there will always be a need for mental health care. Some people, between being born a certain way and having lives that include stress, will become mentally ill for life. There have always been mentally ill people and there always will be. That’s a fact.

2. Stop blaming people for needing help or having mental health issues in the first place. Delaying treatment out of shame only makes things worse because then you have a bigger problem to deal with.

3. We can’t throw them away. They are still people. They have families. They come from somewhere. We are responsible for them. Shirking that responsibility only makes the situation worse for everyone.

4. Out-of-sight, out-of-mind costs money. Treatment in the community costs money. If we want to give people mental health care, either in our community or out of it, it will cost money.

5. Anytime profits get mixed up with care, there will be a problem. The government needs to stop being bought by Big… Pharma, Insurance, Jails, or others which increase the cost of treatment. If you want us to pay less, stop being bought and blaming the victim. 

6.  Reinstate the law that keeps guns from the severely mentally ill. Guns create mental illness in many situations. They certainly don’t cure it.

7. Build houses for the homeless. New studies are showing that a stable roof over their head allows for people to work on their mental health issues.  Addicts and PTSD victims without a place to live seldom get better.

In the end, the only thing that will work is caring enough to help the mentally ill and paying the money to do it.   Treating human beings as the responsibility of the community  — part of the bill for being civilized human beings — is the only way they’ll get care. Not making things worse, while trying to make them better is the answer.  

Still resisting with peace,

 

John