Sunday, June 3, 2018

The New York Times - Steers Mental Health Conversation In the Wrong Direction

An editorial came out today in the New York Times entitled The Crazy Talk About Bringing Back Asylums.  They took a line from President Trump that the Parkland shootings could have prevented if there were more psychiatric beds.  I am  sure was intended to temper any anti-gun sentiment rather than suggest the need for reform of mental health services, but the editorial suggests that this triggered a new debate about the need for asylum beds and looks at (on the negative side) a caricatured extreme view of increased bed capacity.  This political approach to mental health care is exactly what is wrong with policy for the past three decades.

The first mistake in the article is the following sentence:

"Psychiatric facilities are unlikely to prevent crimes similar to the Parkland shooting because people are typically not committed until after a serious incident."

Any acute care psychiatrist can attest to the fact that this is incorrect.  A considerable amount of mayhem, violence and aggression is prevented by the availability of both acute care inpatient beds and psychiatrists treating potentially aggressive people in both inpatient and outpatient settings.  There are no controlled studies of the problem because they would be unethical.  You can't randomly assign homicidal or suicidal people to placebo treatments.  They all have to be actively treated.  At times courts release people who have threatened suicide, violence or homicide without treatment for the associated mental illness and they go on to complete exactly what they said they were going to do.  At other times patients will say that they are very satisfied that they were treated because they recognized they were irrational and about to commit an irreversible act.  The clearest example is the person who is aggressive form the time of admission and the aggression does not abate until they have been actively treated for several days.  People are committed on the basis of all of these scenarios and before serious incidents occur.

Instead of Bring back the asylums they thought they would attempt other slogans to "steer the conversation" presumably about improving the care of mental illnesses in the United States.

1. Demand sensible commitment standards:  

There are essentially just three commitment standards:  dangerousness to self (or suicide potential), dangerousness to others (or aggression and in some cases homicide potential), and grave disability (or an inability to care for oneself).  What could be more sensible?  The problem is that the law is subjective and there is always a way around sensibility.  That workaround could involve a highly aggressive defense attorney with a goal to get the patient "off" rather than worry about any consequences. It could involve a number of administrative issues like the cost of civil commitment (obviously cheaper to not try) or an arbitrary decision by a hospital or court administrator that there are just "too many commitments" and it is time to roll them back- at least until the next adverse outcome.  Another common way around commitment is just to ignore the grave disability standard and in effect say commitment will occur only for dangerousness. If someone really wants to split hairs - the dangerousness has to be "imminent" and it can always be not imminent enough.  For commitment standards to have any meaning at all - they have to be implemented by sensible people.  We need to demand sensible people. More importantly there needs to be accountability and available data from commitment courts on outcomes.

The other part of the problem is that psychiatric beds are so rationed that in order to get into one - managed care organizations say that you need to be dangerous in order to get admitted.  That creates a false burden on court systems who may not be sensible about commitment in the first place.  In the context of this demand they are even less sensible.     

2.  Create a continuum of care:

The NYTimes takes a historical approach going back to the Kennedy era and the deinstitutionalization argument.  First of all there are places that have a continuum of care. The community psychiatry movement was highly successful in following people outside of state hospitals and supporting them in independent living.  Some cities like Madison, WI have a large community mental health center as well as several assertive community treatment (ACT) teams that follow people with serious mental illnesses.

The reason why there is no followup similar to medical and surgical patients with significant disabilities is several fold.  Rationing by the insurance industry and federal and state governments is the primary cause.  It is easy to save money by denying equivalent care to the mentally ill and people with severe addictions.  Over time this has led to separate acute care services in some community hospitals and long term care facilities that are typically run by the state. The large majority of hospitals in most states do not provide acute psychiatric care.  Both acute care and state systems are rationed to provide as little care as possible. It is currently in the financial interest of every managed care and insurance company in the country to maintain this fragmented system of care because it saves them all money.  In the meantime disproportionate amounts of money and resources are funneled to very other type of specialty care.

At the state level, the bed situation is so dire or nonexistent in state hospitals that it should be very clear that they have adopted the managed care rationing plan to eliminate care for the mentally ill.  That is the reason that jails are the defacto psychiatric hospitals at this time.  There is of course no standard for psychiatric care in jails and most people tell me they do not get their prescribed medications.  This is also the reason why asylum care does not work.  Asylums were basically buildings that were poorly managed by the state.

3. Stand up for insurance parity:  

Parity is a joke.  Insurance industry rationing and micromanagement of mental health treatment has continued unabated since the passage of the  Mental Health Parity and Addiction Equity Act.  After watching professional organizations and  mental health advocacy organizations patting themselves on the back after this legislation was passed - it has been more than a little depressing for psychiatrists on the front lines to watch as the denials of care are unchanged from before the bill.  Those organizations have been standing up for parity and against stigma for about 20 years with no results.

It is difficult to get parity when most states have an insurance industry friendly complaint system and the physicians who want to complain are either employees of a managed care company or limited by confidentiality laws.  Standing up for parity is meaningless symbolism at this point. It doesn't require a complicated HHS investigation.  What is needed is a review panel in every state - staffed by psychiatrists who have no financial conflicts with the insurance companies being complained about.  The precedent for those review panels was the Peer Review Organization (PRO) panels that were set up to review all Medicare financed care in the 1980s and 1990s. There is no reason why those reviews should occur today.  The only really effective alternative has been an activist attorney general ordering some of these companies to correct egregious denials of care.  Activist attorney generals do not occur frequently enough to make a sustained difference.

The larger problem is the way that healthcare is funded in the USA. I will add an illustrative post later in the week, but the percentage of the health care dollar dedicated to the treatment of mental illness is at an all time low.  The Hay Report of the 1990s documented the disproportionate drop in health care funding and it seems that governments and insurance companies expect it to stay at that level.

The NYTimes says that all it will take is a "collective will and a decency to act".  Are they serious?  Isn't that all it will take to end mass shootings in public schools?  This is just another naive approach to public policy written by people with no expertise who are ignoring the political landscape.  It is fashionable to call those people stakeholders these days.

As usual the real stakeholders - people with mental illness, their families, and psychiatrists are left out.  The suggested slogans are as problematic as the one about bringing back asylums that the NYTimes was concerned about.

George Dawson, MD, DFAPA


For detailed information about this problem go to the pinned Tweet at the top of this feed and all of the links.


1.  The New York Times Editorial Board.  The Crazy Talk About Bringing Back Asylums.  New York Times June 2, 2018.


Kodachrome slide shot by me in 1982 of Milwaukee County Hospital.  Not an asylum but it looked like one.




  1. The NYT is biased by the same egalitarian mainstreaming instinct that informed Broward policy on adolescent criminal behavior. In other words, commonsense judgment of criminal or mentally ill behavior is simply wrong in their eyes. No one can be judged, except of course, those who do practice judgment. They don't like any policy that isolates either the mentally ill or criminals. What they call collective will is actually a collective unwillingness to accept the fact that some people are too impaired to make it under mainstream rules. We also see this in San Francisco's naive approach to homelessness and drug addiction. Sadly, mental health judges go by this ethos and when I used to go to LA's Court 95, I knew it was a waste of time if the patient could come up with a story that their plan was to live in a cardboard box under a freeway ramp.

    1. Yup! The grave disability standard have been gravely disabled.

    2. I think the ideal solution to this predicament was the old Wisconsin system (it has also deteriorated). In that system there were parallel commitment and protective placement orders. Both occurred on an outpatient basis and the priority was community placement. At the head of a CMHC I could testify for a number of options on patients who were not hospitalized. If a person was gravely disabled the judge would just order them to cooperate with our community support team to secure stable housing. All of this occurred between 1986 and 1989 during the time I was working for that program. I have not found a better approach since, in fact many court encounters were as disappointing as the one you describe.

  2. You missed a very important element, at least that I see pervasively in Community Mental Health Care Facilities. Various elements have basically dumbed down the role of psychotherapy to a point where patients are minimally expected to speak to somebody, but maximally expected to swallow pills / capsules.

    And thus this dumbing-down and diminishing the role of therapy has basically created this de facto biochemical BS model that is destroying the biopsychosocial model that was effective in the 80s and early 90s.

    But, the damage is done, as I have worked in several community health clinics in the past 8 years providing Locums coverage, and almost all the therapists there are either clueless, complicit to minimize their role, or, I think there's an undercurrent of covert intentional carelessness that prompts them to fairly much show no interest in really helping people help themselves!

    Yeah, just my opinion, but one of 25 years in watching the system deteriorate into the basic colostomy bag of minimal effective care it is today...

    Yes, a harsh comment, but, show me where I'm wrong...

  3. Not all CMHCs are created equally.

    There does need to be a quality approach and in many cases they are struggling to keep the doors open (or not).

    Here in Minnesota, we had a large CMHC that served 3 counties just shut the doors with minimal notification to the affected patients.

    I think that therapy is in the tank everywhere, not just the CMHCs. Further evidence:

    1. Even if somebody can do a named therapy (CBT, IPT, DBT, EMDR, etc) it is unlikely that they will get the course recommended in the research literature.

    2. The lack of specificity cab include lumping people who would not be considered candidates for that therapy into a group modality.

    3. The psychiatrists involved in CMHCs are often told they need to see a person every 15 minutes - not much time for a therapeutic discussion.

    4. It takes quite a bit of training to treat severe personality disorders and without that training there are often disruptions in care due to splitting and severe acting out.

    I think there is a role to help get some of this back on track if there is enough time for group supervision and training for specific situations, but you are correct - the predominant "med management" mentality minimizes the role of therapy and can produce a very low quality product.

    In the past ten years I have seen collections of good therapists deciding to work outside HMO or county owned systems and they seem to do a good job of offering quality therapy and staying a afloat. Their clinics often specialize in a particular problem like anxiety, PTSD, or grief.

    Interesting that you should mention biopsychosocial. Will be writing a critique of that model and hope to post it within a week.

  4. Thank you for sharing your opinions on latest NYT article.

  5. I was reminded in a recent Psychiatric Times article by our genius overlords that therapy is the seventh option when antidepressants fail. After a number of augmentation and substitution strategies.

    I remember when that kind of talk would get you mocked out of residency. I remember when recommending medication on a consult patient you never saw would get you thrown out of residency.

    For all this top-down emphasis on bio, I don't really see a lot of real bio going on, just drug pushing. Why aren't we looking at Vitamin D levels, metabolic status, and CRP-HS?

    Obviously with schizophrenia and severe mood disorders, drugs play a more important role, but not the only role.