NHMH NO HEALTH WITHOUT MENTAL HEALTH A 501(c)(3) non profit   San Francisco - Washington DC Director’s blog

Published Monday 12 of May, 2014

In 1858 Abraham Lincoln warned the nation: “A house divided against itself cannot stand.”

As we confront a mental health crisis in this country, it is time to remind ourselves of those words.

In the behavioral health (mental health/substance use) field, we now have a seriously divided “house.”

In 2014, we are in the throes of an unresolved national crisis of untreated or poor quality mental health/substance use care. 60% of patients with BH conditions receive no care at all. Of those minority who do receive care, only 1 in 9 receive evidence-based care. As a nation, we have experienced a series of horrific national tragedies with most linked to untreated mental illness. The latest evidence of the behavioral health divisions that mar our progress is the dueling mental health legislative bills introduced in the U.S. House of Representatives in 2013 and 2014, both ostensibly meant to respond to Newtown and other tragic violence by individuals with untreated mental illness, but both bills influenced and burdened by the basic divide in the BH field, and shaped to some degree by partisan politics. When what we need is a bipartisan approach, with patients coming first.

In broad terms, the split in the BH field is between the Recovery/Resilience Model and the Medical Model. Patients, families, advocacy organizations, clinicians, elected officials, government agencies responsible for behavioral care at both federal and state/county level, are all caught up in the split. Instead of moving the mental health quality care agenda forward, we’re engaged in internecine fights.

The recovery model puts first and foremost patient hopes and aspirations for recovery where possible and resilience to lead as fulfilled a life as possible despite their behavioral condition. It stresses the role of “peers” or other patients with lived experience of behavioral conditions, and is generally aligned with an important new social movement on patient engagement and empowerment. However, this view often perceives the medical model as focusing exclusively on pathology, causes and effects of disease, and treating pathology, while they view themselves as reinforcing positive aspects of patients and moving toward recovery.

The medical model prioritizes treatment first, rightly pointing out that 60% of patients with BH conditions in the U.S. receive no treatment at all. If a patient with a serious mental illness is hearing voices and feeling paranoid, it will be difficult, especially without treatment, to build on positive aspects of their personality and move towards recovery.

There are elements of truth in both models, and our challenge now is to create a balanced approach to behavioral health care that includes the best parts of the recovery model and of the medical model.

In order to achieve a balanced, inclusive approach, we can:

  1. Come together in an effort to listen non-judgmentally, and develop the capacity to see the merits in the others views;
  2. Begin to undertake an active search for common ground. What is it in the other side’s position that can be agreed to and built on? Can we draw on data and documented outcomes and lived experience to find approaches that work;
  3. Accept that if we do not find a balanced approach, we may lose this time-limited window of opportunity to reform and improve the mental health system, and this possibility of failure should be uppermost in our minds and drive our efforts.

The undersigned speaks with some degree of experience and insight as I have had two siblings with serious mental illness and lived with them, or been their caregiver over most of my adult life. I have also been, and am now, an active advocate for quality, coordinated, cross-disciplinary medical-behavioral treatment and care. Our family put the best interests of our loved ones first, so often that did indeed focus on a search for the best available treatment. We came to learn that a good psychiatrist, knowledgeable, experienced, caring, sensitive to patients and open to trying new approaches is worth their weight in gold. We need to clone the good ones, not minimize all of them.

We also came into contact with BH practitioners who, unintentionally or otherwise, stigmatized their BH patients, treating them like children, or seeing them only as “disorders” not human beings. We saw the pernicious effect such negative, devaluing, insensitive approaches have on patients, our loved ones, lowering their sense of self-value, especially over the years, which is the time-frame involved with the most serious mental illness. It was/is very sad to see. And don’t think patients don’t feel it. They do.

It is understandable that the recovery movement is driven to see patients with BH conditions as human beings first, and to offer them hope, and to give them prospects of being able to function productively in our society, and peer counseling offers one avenue. Plus, such lived experience is an undeniable advantage when trying to reach out to others newly struggling with these disorders. The prospect for work as peer counselors can be hugely important for consumers – at the same time, clinicians who can add value to patients health outcomes should play their vital role.

However, the recovery model advocates do everyone, including patients, a disservice, when they minimize or try to de-emphasize the role of BH professionals and the need to for treatment’s central place. BH practitioners should be trained in how to treat their patients in a way that does not stigmatize or diminish nor reflects insensitivity. It’s not an easy profession, oftentimes, BH practitioners need the patience of Job. But the point is recovery advocates make a mistake to minimize their essential role in care. On the contrary, BH professionals are vital to quality evidence-based care.

Both the recovery model and medical model are important; let’s work towards a balanced approach.

Florence C. Fee, J.D., M.A.

Executive Director