By Dr David Laing Dawson
Through the 1970’s into the 1980’s I ran what we called Community Psychiatry Services. They were General Hospital based and consisted of teams of psychiatrists, nurses, social workers and psychologists. We used what we called an “Active Intake” process that ensured that the severely ill received appointments very quickly and the worried well were rerouted to other agencies. The “active” part of the intake process was a pre-appointment engagement of the patient, the family, the other caregivers. Doing this required that the clinic not become specialized, and that it did not have exclusionary criteria.
The second component necessary for this is a true team, with each member involved, the care plan decided by the team led by a psychiatrist, and that the nurses and social workers be willing to function as case managers. It also required that each member of the team be prepared to help with medication compliance and monitoring, medical care, budgeting, finding bus passes, talking to families, giving shopping lessons, helping with all activities of daily living and also counseling.
Doing this work requires a high tolerance for chaos, uncertainty, anxiety, and insanity.
Several things I think, though it is difficult to see the forces of change while living within them.
1. The length of stay in hospitals for the mentally ill became shorter and shorter, driven at least in part by spurious management and budget ideals.
2. The mental hospitals continued to downsize, in some part as a naive ideal, but mostly as a means of shifting cost (and responsibility) from Province and State to Community and Federal Governments. (Note the stats of the Chicago area show an exact mirror image between the declining numbers in hospitals, and the inclining numbers in jails and prisons from 1970 to 2010)
3. The general Community Psychiatry Service is not a good academic career choice. Academics need to specialize for teaching and research opportunities. Hence the development of Anxiety Disorder and Bipolar Clinics. This doesn’t work for the severely mentally ill because to satisfy all the research and protocol needs the waiting list is long, the assessment phase onerous.
4. Again, based on naive idealism, many community services shifted location from the hospital to the community. But once a clinic is moved away from the hospital (geographically and managerially) several things happen:
a. They can no longer risk taking disorganized, chaotic and potentially dangerous patients and
b. Non-medical and non-psychiatric philosophies start to dominate, and the severely ill are excluded. And
c. (at least in my experience) away from the stable budget and managerial practices of a hospital, strange things happen, all the way from pop psychology to fraud.
5. I suppose it was inevitable that each discipline develop more of a sense of autonomy and independence. Social workers and other mental health professionals are no longer case managers working with psychiatrists. They are independent counselors. The development of simplistic models of counseling (CBT and DBT) which can be applied once per week for ten weeks helped this along. This has also contributed to something of an anti-pharmaceutical attitude. (By the way, there is no evidence that CBT is any more helpful than any other professional counseling relationship, but being a rigid simplistic set of responses it is easier to study)
6. I am also convinced that by putting addictions and mental health (illness) under the same umbrella, we diluted what sympathy and empathy the community was developing for the seriously mentally ill.
7. This was compounded by the so-called recovery model, which at its heart, really means (and this may be appropriate for addicts) that if you really try hard enough and think only good thoughts (CBT), and are sufficiently “supported”, you can get well and recover fully.
8. The corollary of this being that if a person with a psychotic illness is not recovering it just means he is not trying hard enough.
9. De-stigmatization. I just happened to watch “Big” the other night and noticed that the actor who played a walk through part, non speaking, looking homeless and mumbling to himself in downtown New York, was listed in the credits as playing “Schizo”. The real way to de-stigmatize any illness is not by feel good infomercials, but by providing adequate and successful treatment. Think Leprosy, AIDS, cancer.
10. Without a team to work with, to case manage, to field crisis calls, to make home visits, to check on progress more frequently, a lone psychiatrist will find it difficult to treat the severely ill.
11. The tightening of the mental health acts and processes in each state and province, the protection of individual rights and the provision of due process (as defined by lawyers), again based on a sort of naive idealism, resulted in four unintended consequences: thousands of people suffering from untreated psychotic illnesses in the streets and shelters, a burgeoning population of mentally ill in the prisons, the dramatic growth of locked Forensic Psychiatry Units, and a sad return to locked doors for the rest of the hospital now dominated by the Forensic units.
Between 1900 and 1960 the severely mentally ill were mostly institutionalized, treated in mental hospitals for long lengths of stay, by doctors who were often imported and/or had limited licenses. Then as now, the Academic and North American trained psychiatrists worked in private offices treating a small number of patients over many years. These patients could be counted on to be articulate, educated, and at least middle class.
Between about 1960 and 1990, with new effective medications and the move to de-institutionalize, community clinics like the ones I worked in developed in many parts of North America; the General Hospitals developed psychiatric programs, and for at least two decades, perhaps three, we seemed to be moving in the right direction. In parts of Canada incentives were developed to keep psychiatrists working in hospitals with the severely ill or as they were called then, the seriously and persistently ill. And the University Departments of Psychiatry finally took an interest in the medical treatment of the severely mentally ill.
We were going in the right direction.
And now it seems we must re-invent the wheel.
For more information on schizophrenia, check out the documentary Schizophrenia in Focus