Nathaniel S. Lehrman, retired M.D.Clinical Director,of the Kingsboro Psychiatric Center, wrote the following essay for the ISPS (The International Society for the Psychological Treatments of Schizophrenia and Other Psychoses) conference in December. He points out the central importance of continuity of care and expectation of recovery without the narrow biological model of mental illness, ingredients also found in the Open Dialog approach in Finland.
Why Nation’s Mental Health Care System Problems Remain Uncorrected
An effective care system that I saw – and then set up
I saw an effective care system for hospitalized psychotics in Cambridge,
England, in 1978. The same psychiatrist who treated a patient in hospital
followed him afterward in the clinic until discharging him as recovered.
For me, who had just retired as Clinical Director at Kingsboro Psychiatric
Center in Brooklyn, this was truly “a road to Damascus” experience.
I repeated what I saw in England when I returned to another New York state hospital as a part-time, after-care staff psychiatrist. That repetition was the most exciting and satisfying professional experience of my entire life. Expecting that my unselected aftercare patients could recover, staying in touch with them even when they needed brief rehospitalization, and working with them on their unique individual problems, fears and relationships, I gradually helped over a hundred toward recovery.
The essential elements in this successful approach were (1) continuity of
care – care by the same professional from start to finish of treatment – and
(2) the expectation that full recovery could be attained. That expectation
came in part from my own experience – full recovery from a schizophrenic
break in 1963. Later, several colleagues, reflecting the hopelessness long
pervading psychiatry, insisted I was incorrectly diagnosed because I did
Loren Mosher, researchers in northern Finland, and others have done
essentially what I did, altho in different ways. But common denominators
for them all are continuity of care and the expectation of recovery.
Psychiatry’s justified gloom
Why then the gloom which has long pervaded psychiatry? Thomas Insel, M.D., Director of the National Institute of Mental Health, wrote recently (Arch. Gen. Psychiatry 2009, p. 129), “In contrast to the steadily decreasing
mortality rates of cardiovascular disease, stroke and cancer, there is no
evidence for reduced morbidity or mortality from any mental illness.” There has been “no change in the prevalence of mental illness between 1992 and 2002, but increased rates of treatment… from 20% to 33% during this ten year period. Curiously, despite increased treatment, there was no evidence for decreased disability. Indeed, the more recent cohort shows a loss of income that is considerably greater than all previous reports.” In other words, psychiatric treatment seems increasingly unsuccessful.
What’s more, mental illness represents a mounting fraction of all disabling
illnesses. Insel notes that “the World Health Organization Global Burden of Disease study listed mental illnesses as the leading source of disability in
Americans and Canadians aged 15 to 44 years, accounting for nearly 40% of
all medical disability in this age group.”
Two reasons for this increasing failure are (1) the mounting fragmentation
(discontinuity) of mental health care, and (2) therapeutic fearfulness and
hopelessness, the latter often being “explained” by the alleged biological
basis of mental illness. Over-reliance on medication as our primary
treatment modality has resulted. Organizational changes within public
psychiatry have aggravated these failure-producing factors: discontinuity
of care and evocation of fear instead of hope – sometimes deliberately.
The mounting fragmentation of care
Until 1979, at New York State Office of Mental Health facilities, the same
chief of service headed both in-patient and aftercare facilities for a given
catchment area. Then a statewide reorganization placed all aftercare
services under one assistant director, thus giving two administrators
sequential responsibility for patients instead of one.
In 1984, aftercare services for New York State facilities were transferred
from hospital-based clinics to private agencies. As of 2002,the state had
2,378 such agencies.
In Cambridge, England, the continuity of care system I admired was later
discontinued – in order to facilitate research, I was told. In Israel, while a continuity of care system was admittedly desirable, its implementation was supposedly prevented by psychiatric training needs.
The centrality of continuity of care was the heart of my paper on “Effective
Treatment of Chronic Schizophrenia” at a panel I organized on treating
chronic patients for the American Psychiatric Association’s 1980 annual
meeting. But the term was redefined in another panel paper (“Continuity of
care: a conceptual analysis,” by a University of Maryland sociologist) as
“the orderly, uninterrupted and unlimited movement of patients among the
diverse elements of the service delivery system” – as though such care-fragmenting “movement among” agencies was both acceptable and inevitable. Her paper was lead article in 1981 in the American Journal of Psychiatry, its author was then invited to present its thesis all over the country, and the American Psychiatric Association repeatedly honored her for it. After my paper appeared in 1982 in an obscure journal, I received three or four reprint requests. If fragmented care is thus accepted as inevitable, who will try to change it?
The deliberate evocation of fear and hopelessness Mental patients rarely, if ever, recover beyond their caretakers’ expectations. When caretakers are hopeful, patients will tend to be also. But when caretakers are fearful and intimidated, patients suffer accordingly. The dangerous extent of that fear today is shown by a recent report that many mental health commissioners place their role in ensuring public safety ahead of their treating the mentally disturbed.
In 1979, a fear epidemic was deliberately created throughout New York
public psychiatry after “mental patient” Adam Berwid, on authorized hospital pass, premeditatedly slaughtered his ex-wife. Then, with a local prosecutor standing beside him, he lied to the media that he had warned his doctors of his plans, but they gave him the fatal pass anyway. With the media’s unquestioning acceptance of the murderer’s officially supported lies, psychiatrists at that hospital became totally panicked – afraid even to write orders without the consent of their nurses (a nurse had just been appointed hospital director). The psychiatrist chief-of-service involved in the case needed hospitalization after refusing, despite two weeks of pressure from the state mental health commissioner, to confirm the latter¹s claim that he had ordered the ward psychiatrist not to issue the pass. It took two years before the killer was finally found guilty of murder and given a maximum sentence. But the fear which reverberated throughout the care system did not help its patients.
Effective care of the mentally disabled requires continuity of care and hope
for recovery. The latter can be eclipsed by the creation of fear. The Berwid
case is a striking example of that fear-creation the active sabotage of mental health care by some of the professionals organizing and providing it. Psychiatry will continue harming its patients until those within the profession responsible for that harm are brought to public attention and dealt with appropriately.
Nathaniel Lehrman can be reached at nslmd(at)verizon(dot)net