Fixing the Mental Health System: Some Starting Points

by Tony Salvatore, M. A.

Every time there is some event anywhere involving mental illness in any way there are cries to “Fix the mental health system!”  There is no denying that the US mental health system needs “fixing” but perhaps we need to look more closely at some of the reasons that this is so and at some of the efforts underway to at least mitigate this state of affairs.

Government under-funding has compelled some providers to “cherry pick” and focus mainly on healthier, wealthier patients.  However, at the same time, the mental health system has become the default provider for the problems that the other community services “silos” do not elect to help.  Some individuals with serious mental illness may go underserved because many mental health providers are dealing, often ineffectively, with clients who have dementia, substance abuse disorders, intellectual disability, and little, if any, mental illness.

Psychiatric beds exist for those who require inpatient psychiatric care because they are a danger to themselves or others due to psychiatric emergencies, such as suicidality or psychosis, or serious illness-related mental health crises.  In most communities there are a dearth of such resources.  Where they are present they may be largely occupied by people who do not need this level of care but for whom other options are unavailable.  Scarce beds may also be filled with treatment-seekers and malingerers.  Such individuals do not benefit from inpatient psychiatric care and deny treatment to those who might.  Psychiatric hospitals have become “Plan B” for the rest of the mental health system as well as for other service sectors.

Efforts are being made on many fronts to divert individuals at risk of incarceration from contact with the criminal justice system.  Police are unavoidably “mental health first responders” because of their public safety role.  In many areas, mental health providers have acted to assure they are trained to recognize signs of potential mental illness and how to safely deal with an individual with severe mental illness.  Montgomery County Emergency Service has been providing such training to local law enforcement agencies and others since 1975.   Elsewhere, police departments have adopted the Crisis Intervention Team (CIT) model.  Programs of this nature divert many whose criminal justice contacts are related to their mental illness from arrest and prison.

Mental health courts are in place and reduce the likelihood of imprisonment of those with mental illness whose offenses are serious enough to bring them into the court system.  Routine court oversight of treatment adherence brings the weight of the judicial system to bear and assures that all parties to care arrangements live up to their responsibilities.  In our service area the “intercept concept” has been used to identify points at which persons with mental illness can be diverted from the criminal justice system.  One “intercept” point with high potential for re-incarceration is after leaving prison.  Forensic outreach services can facilitate community re-entry and providing mental health training to probation and parole personnel to reduce “violations” related to mental illness.

For those with mental illness already in prison or who were not candidates for diversion, the correctional system in some states making changes  In Pennsylvania, for example, the Department of Corrections is creating special housing units for inmates with serious mental illness “who do not fit in well with the rituals of prison life.”  This approach, while far from optimal, establishes settings that may not worsen the existing mental illness, offer some protection to vulnerable inmates, and lessens assignment to solitary confinement.  This addresses the reality that some offenders belong in the correctional system but should be able to access appropriate mental health care when needed.

What our discussion so far shows is that perhaps there is really no such thing as a “mental health system” anymore but rather that mental health-related functions have been dispersed as the entity once charged with managing them has proved increasingly unable to do so.  This may provide an opportunity to resolve the problems presented by the Cartesian mind-body split and adopt a holistic model of health care treating all illnesses and disorders whether based in the brain or in other organs.  This is occurring as behavioral health professionals are being integrated into both primary and specialty health care practices.  Such integration will enhance the effectiveness of psychopharmacological therapies and provide for more effective resolution of side effects and drug-to-drug reactions.

Recently, ethicists at the University of Pennsylvania (JAMA, December 2014) called for a “return to asylums” as a “fix.”  It is unlikely that re-institutionalization will ever take place.  Nonetheless, dismantling the state hospital system did not obviate the need of some individuals with severe and chronic mental illness for long term residential care.  While there will be a need for psychiatric hospitals to stabilize those with acute exacerbations of chronic mental illness, there is really no need for even a state hospital level of care thereafter.  Many patients could be “stepped down” to sub-acute levels of care for stays of three to six months during which treatment plans could be developed with the involvement of the patient, family, and outpatient providers.  Such transitional care could prevent the rapid re-entry stressors of discharges to home from inpatient psychiatric care that drive revolving door re-admissions and drive patients unable to engage with outpatient care to homelessness, substance abuse, and, in too many cases, police contact.

To sum up, perhaps a mental health system that served people whose primary needs primarily related to mental illness would need less fixing than one serving all comers, being all things to all people, and poorly serving all.  Perhaps the best way to fix the mental health system is to assure that other systems do their jobs rather than off-load those they do not wish to serve.  Once this is done attention can be given to deficiencies inherent to the mental health system.

The Music of the Mind: A Diverse & Unique Inpatient Psychiatric Hospital Concert Series

by Gabriel Nathan, M. A. Ed.

There is much that has been written about the intersection of behavioral health treatment and the creative arts.  For decades, certified music, art, dance & movement, and drama therapists have been working with individuals with mental health challenges in ways that enhance and complement the more traditional therapeutic modalities the “medical model” has to offer.

At MCES, patients attend a wide variety of psychoeducational and recreational groups every day of the week, from 9:00am-9:00pm.  These groups can range from Fitness Walking to Suicide Prevention, Coping with Anxiety to Learning Forgiveness, to Trauma and Medication Education to Creative Writing.  While the days on the inpatient unit are filled with opportunities to learn, share, gain insight and feedback, once a month at MCES there is an opportunity to experience something special, outside the realm of what is traditionally thought of as “treatment” or “therapy.”

In 2014, two foundations, The Clayman Family Foundation and the E. Rhodes & Leona B. Carpenter Foundation both awarded MCES grants to fund a year-long concert series on MCES’s inpatient unit.  The notion of having performances for individuals experiencing inpatient treatment is not new, but it has rarely been formalized to this extent, supported by philanthropy, and attracted a such a diversity of talent:

LoewySusanna Loewy is a twice GRAMMY-nominated flutist and educator who lives in Philadelphia.  She has performed with Peter Nero & the Philly Pops, the Philadelphia Orchestra, the Pennsylvania Ballet, and the Louisiana Philharmonic Symphony Orchestra.  Susanna played at Carnegie Hall in 2013, premiering the new works of three contemporary composers.

Susanna’s June 25th concert was her second time back at MCES, and she performed a variety of works from classical to contemporary.  Susanna had performed a Valentine’s Day concert at MCES on February 13th.

MCB2The Merion Concert Band was established in 1977 with the aim to “foster and promote music and the interests of music in the community.”  Since that time, it has grown to become one of the most popular bands of its kind in the area, producing a well-attended annual concert series and attracting professional musicians to play alongside their amateur performers.     

On July 10th, over forty members of the Merion Concert Band played an unforgettable twilight concert in the MCES outdoor courtyard for dozens of enthralled patients and staff.  It was a night to remember.

Nicole Zell 3 (2)Nicole Zell is a singer-songwriter and a mental health advocate, making her a natural choice to perform at MCES.  She has performed in a variety of venues over the last five years, and hosts a radio show called “Soundstage” on WCHE-1520 AM Radio.  Nicole is a member of the Chester County Suicide Prevention Taskforce.

Nicole’s emotional hour of music in September was compelling and revealing about some of her personal struggles, and her music, words, and thoughts resonated with the patients and staff in a powerful way.

Deirdre Flint @ MCESDeirdre Flint was born and bred in Philadelphia, and her music is a blend of hilarity and sincerity.  One minute, she can make you howl with laughter at songs mocking Facebook, bridesmaids’ dresses, or being flat-chested, and the next you could be crying as she sings about the memories of her grandmother’s house.

Also a substitute teacher in the Philadelphia School District, Deirdre Flint’s songs are instructive in nature: about how not to take oneself and one’s world too seriously, about how laughing in the face of adversity can be an essential coping skill.  Deirdre’s unique, funny, and down-to-earth performance at MCES filled the cafeteria with laughter and applause for this one-of-a-kind singer-songwriter.

Staines & Zell (11-21-2014)Bill Staines is perhaps one of the best-known names in folk music today.  He has recorded twenty-two albums over his 40-year career, and travels over 65,000 miles annually, playing at 200 venues nationwide.  Bill has performed on national radio shows “Mountainstage” and “A Prairie Home Companion” and his songs have been featured in several major motion pictures.

On November 21st, Bill Staines traveled from his home in New Hampshire to MCES to perform a set of some of his most memorable and well-known songs for an appreciative audience of staff and patients.

Nicole Zell was warmly welcomed back to MCES to play an opening set for Bill Staines.

The Norristown Chorale has been singing in and around Montgomery County since 1977, performing two main concerts annually for the benefit of the community.  They have performed with the Ambler and Pottstown Symphony Orchestras and have presented Mozart’s Requiem and Handel’s Messiah. 

On December 17th, 50 members of the Norristown Chorale filled the MCES gymnasium with the glorious sounds of Christmas, singing a mix of traditional carols, hymns, and popular songs about the Christmas holiday—a special, heartwarming treat for those who had to be hospitalized so near to Christmas.

Opera North, Inc. is the oldest African-American opera company in Pennsylvania.  They produce and perform new works, full-scale productions, concerts, and educational outreach engagements.  Their director, Leslie Burrs, is deeply invested in connecting with the mental health community.  Opera North, Inc. recently collaborated with the Philadelphia Department of Behavioral Health & Developmental disAbilities on a video project documenting mental health recovery.

Soprano Iris Fairfax, baritone Dan Lickteig and accompanist Pasquale Montenegro of Opera North, Inc. performed a pleasing blend of opera, operetta, and musical theatre pieces for an attentive and engaged audience in January.

Doc Gibbs & Cachet IveyDoc Gibbs performed at MCES on February 16th, along with dancer and instructor Cachet Ivey.  Doc brought along with him percussive instruments from around the globe and had patients performing with him and with each other.

What, to the casual observer, looked like a simple box or a George Foreman grill, Doc Gibbs was able to turn into expressive, tuneful instruments that had people up and moving to Doc’s rhythms and Cachet Ivey’s infectious moves.

Doc Gibbs has performed with Erykah Badu, Wyclef Jean, Grover Washington, Jr. and many others.  He was also the bandleader on the “Emeril, Live!” show from 1997-2007.

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Individuals receiving inpatient behavioral health treatment have the same need to experience creativity, artistic expression, and enjoyment of culture as anybody else.  Unfortunately, for many with mental illness diagnoses, access to the arts is severely limited by myriad factors, and inpatient hospitalization is an obvious disruption to an individual’s ability to experience arts and culture.  Through the generosity of the Clayman Family Foundation and the E. Rhodes & Leona B. Carpenter Foundation, we are able to bridge the gap between culture and treatment and offer high-quality performances to our patients and staff, and let the music continue.

Suicide Attempt Survivor Support: A Critical Unmet Need

Montgomery County has a serious problem with suicide, losing over one-hundred residents yearly.  It is probably less well-known that the county has a much bigger problem with non-fatal suicide attempts, all of which raise the individual’s life time suicide risk, and many of which subsequently become fatal attempts.

There is little data on the incidence of suicide attempts, an act in which a person with intent to die acts on a plan using potentially lethal means.  Many attempts occur without coming to anyone’s attention. Those that do usually are as a result of a need for medical treatment, self-reporting by the individual in seeking help, or when there has been an intervention.

Depending on age and gender, the ratio of suicide attempts to fatalities varies widely. Youths make more attempts than adults, men make considerably fewer attempts then women, elders tend to die on their first attempt.  Lethality of means, particularly firearms, accounts for these disparities.

Individuals with serious mental illness, especially schizophrenia, bipolar disorder, and major depression, attempt suicide more frequently than those without these conditions.  Alcohol abuse and dependence figure highly in suicide attempts. Imminent and actual suicide attempts account for a significant number of voluntary and involuntary psychiatric hospitalizations.

We could go on, but suffice it to say that focusing suicide prevention on individuals who have made a suicide attempt would likely save a lot of lives, enhance the recovery prospects and duration of those who may re-traumatize themselves when beset by even passing suicidal thoughts, and free up ERs and psychiatric hospitals to address other needs.

In 2012, the Action Alliance, a national suicide prevention coalition, identified support for attempt survivors as a priority for focus in the revised National Strategy for Suicide Prevention (NSSP).  This led to a national Suicide Attempt Survivors Task Force to help forge a path for stopping suicide attempts and deaths by engaging and supporting people with lived experience of a suicidal crisis.

In 2014, the Pennsylvania Adult Suicide Prevention Plan included an objective (9.1) to “identify all suicide strategies and services that respond to and care for individuals affected in the aftermath of a suicide attempt…and promote awareness of these resources.”  This state plan will presumably motivate the implementation of aftercare resources for suicide attempt survivors at the county level.

 

There are few suicide attempt support groups anywhere.  A 12-step based “Suicide Anonymous” group met for several years in Norristown, but ceased when its leader moved out-of-state.  At present, the only such support resource that we know of anywhere near Montgomery County is a “Suicide Anonymous” group in Burlington County, NJ:

Rise Above/R.I.T.E. Center

Twin Oaks Community Services

693 Main Street Building C

Lumberton, NJ 08048

1st Floor, Center Door

Group and Skype: 7:00pm 2nd and 4th Thursdays

Skype Only: 1st, 3rd, and 5th Thursdays

 

So why such a paucity of support groups in a major metropolitan area that probably has support groups for every other malady known to humanity?  Liability for self-injury or fatalities among group participants is often cited.  This probably would not apply to a peer-led group and has not proved insurmountable in the few provider-based groups around the country.  Bigger problems are stigma and finding peer facilitators.  (It is likely that there are a number of Certified Peer Specialists who have “lived experienced” of a suicide attempt as well as group facilitation skills.[i])  Indifference toward the needs of attempt survivors is an issue.  Perhaps those affected by recurrent episodes of acute suicidality will at some point step up.

 

Repeatedly hospitalizing those who make or almost make suicide attempts may be more part of the problem than part of the solution.  Clearly inpatient care may be indicated for stabilization and safety but there is no evidence of any long-term preventive value.  Moreover, the first 30 days after discharge from a psychiatric facility are a very high risk period for suicide.  Many readmissions within 30 days of discharge involve suicidal behavior.

 

Here are some on-line information resources on this topic:

 

 

 

[i] See “Peer Specialists can Prevent Suicide” Behavioral Healthcare, September 30, 2010 at http://www.behavioral.net/article/peer-specialists-can-prevent-suicides