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.