Wednesday, December 26, 2012

Psychiatric opinion on same-sex marriage is more acceptable than an opinion on violence and aggression

I was surprised to see an insert in my psychiatric newsletter this month describing the efforts of four major mental health professional associations in opposing an amendment to the state constitution that would exclude same-sex couples from legal marriage.  The Minnesota Psychiatric Society, the Minnesota Psychological Association, the Minnesota chapter of the National Association of Social Workers, and the Minnesota Association of Marriage and Family Therapists produced this document that in essence says that there are no research findings to suggest that children from same-sex parents differ from heterosexual parents in outcomes.  The newsletter editor's column explains that there is apparently no policy on the MPS taking a stance on political and societal issues.  She put that question out to the general membership.  MPS President Bill Clapp, M.D. stated the issue succinctly:

"The MPS Executive Committee was painfully aware that the development of a consensus statement regarding marriage amendment could not possibly represent the diverse opinions of all Minnesota psychiatrists.  On the other hand we felt a responsibility to act faithfully in representing our many patients who believed the marriage amendment violated their civil rights and was overtly discriminatory". 

I think there are a number of issues relevant to this opinion that are interesting to contemplate.  First and foremost is bias in the media.  Over 2 years ago the MPS partnered with two other mental health organizations The Barbara Schneider Foundation, and SAVE - Suicide Awareness Voices of Education in producing a statement on violence prevention.  That statement highlights the lack of mental health resources, lack of training in dealing with these incidents, and the lack of quality standards in assessing and treating patients having problems with violent and aggressive behavior.  That statement was rejected by the newspaper editor. The only reason given was a potential conflict of interest because we were advocating for research and that nonspecific advocacy was viewed as a problem.  In the two years since the statement was produced, it is clear that the issues we raised are as important as ever.  My first question is why that statement pertaining to issues that mental health clinicians and the organizations involved deal with on a day by day basis was not acceptable and a statement on a purely political issue was.

I personally voted against the constitutional amendment and think that any reasonable person would.  None of my criticisms of this initiative outweighs the value of getting the research literature out there for public consumption.  It may have been useful to provide a link to all of the available research in an easily accessed format like Medline.  

On the other hand after treating violent and aggressive people and people with severe mental illnesses and addictions for 23 years, it seems like using a professional organization to take a political position on same sex marriage is a stretch.  One could argue that anything that affects the nurture of individuals is relevant to psychiatry, but there are probably few psychiatric societies that take positions on those topics.  I do think this illustrates that the media is much more willing to accept psychiatric opinion on a purely social and political issue, rather than an issue that is immediately relevant to the practice of psychiatry.

I have two minor objections about this initiative. First, it is too easy. The majority of psychiatrists are Democrats and psychiatry is the only medical specialty where that is true. It is fairly predictable that the majority of psychiatrists would support this initiative.  It is good to know that the position is supported by scientific data but I don't think that fact or the fact that psychiatrists support a political measure would carry any weight with voters.  Given the negative press associated with psychiatry and the tendency of the press to to cast psychiatry in the worst possible light, there is also the question of possible backlash against any measure supported by organized psychiatry.  The negative press about the DSM5 and antidepressants are two good evidence based examples.

My second objection is that there are numerous problems that affect psychiatric practice on a day-to-day basis where there should be immediate and very aggressive political action. Some of these topics have been ignored for decades at both the state and national levels. If I had to come up with a top 10 list (no particular order) it might look something like this:

1.  The intrusion of managed care into the practice environment.
2. The intrusion of pharmacy benefit managers into the practice environment.
3. The intrusion of managed care practices into government-funded programs.
4. Mismanagement of public facilities.
5. Mismanagement of quality measures at the population level in the state of Minnesota.
6.  The lack of timely care of acute psychiatric problems (considerable overlap with number one above).
7. Poorly thought out guidelines for reimbursement of psychiatric care emphasizing low quality high volume medication focused practices as opposed to psychosocial treatments that are often as effective.
8. Lack of uniform application of civil commitment statutes on a county by county basis.
9. Lack of crisis intervention services in more than half of Minnesota counties.
10. Inadequate residential services for people with chronic mental illnesses, addictions, and children with psychiatric problems.

In terms of a guiding principle, a professional organization needs to advocate for what adversely impacts its members every day. When you have issues on the above list that are not only pressing but have been pressing for two decades the question becomes: "Why has nothing been done?"  It is much more uncomfortable to do something relevant to every practicing psychiatrist than something that most psychiatrists would have done anyway.

The other factor is that none of the issues on the list was ever voted on.  This is a key dimension in American politics.  Business lobbyists working behind the scenes at the state and federal levels generally get what they want flying under the radar.  They are there every day pushing a pro-business and in many cases pro-government agenda.  The last thing they want is any political reform that actually tips the balance in the direction of patients and physicians.

There were no referendums or amendments put up for a vote when the Minnesota statutes were rewritten to favor managed care companies.  That is where the heavy lifting is for professional groups in American politics and that is where MPS needs to be.

George Dawson, MD, DFAPA

Daniel Christensen, Kathleen Albrecht, Bruce Minor and Bill Clapp.  Children parented by same-sex couples do just fine.  StarTribune October 28, 2012

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