“For too many Americans with mental illness, the mental health services they need remain fragmented, disconnected and often inadequate, frustrating the opportunity for recovery…. Instead of ready access to care the system presents barriers that all too often add to the burden of mental illnesses for individuals, their families, and our communities.” Those were the words of the President’s New Freedom Commission on Mental Health (2003), which went on to recommend “a fundamental transformation of the nation’s approach to mental health care.”
Six years later the U.S. mental health system remains badly broken, but with health care now a front-burner issue the opportunity for reform may finally be at hand, making the release of Timothy A. Kelly’s “Healing the Broken Mind” (NYU Press) particularly timely. In the book, Kelly—Director of the DePree Center Public Policy Institute, as well as Associate Professor of Psychology at the Fuller Graduate School of Psychology in Pasadena, California—not only explains how and why America’s mental health system is in shambles, but provides a clear road map for transforming it into a sustainable, effective model of care.
Last week Kelly spoke with Failure about the book and his comprehensive plan for making mental health care treatment both accessible and effective.
What prompted you to write “Healing the Broken Mind”?
Thirty years in the mental health field. But the capstone of that was my serving as Commissioner of Virginia’s Department of Mental Health from 1994-97. As Commissioner I saw things most people don’t see. For instance, I would make surprise visits to psychiatric facilities across the state, where I found that the care being provided was closer to custodial care [“a fancy term for babysitting,” explains Kelly]—than anything else.
While there were programmed activities—on paper, at least—I often found staff and patients alike lounging around on couches watching TV, waiting for the patients’ meds to kick in. And once their meds kicked in and they were stabilized, they would be discharged into the community. They would be given minimal follow-up care, usually a once-a-month meds check. So they would eventually spiral down and deteriorate and be readmitted to the hospital—a vicious cycle that is very costly, both for the individual on a personal level and for the state on a financial level. Seeing that over and over again lit a fire in me. I’ve been speaking and writing about mental health reform ever since.
Why is the U.S. mental health care system in such bad shape?
[In the mid-20th century] America went through an institutionalization process where we built facilities to house individuals with serious mental illness. In the 1950s, at the height of that era, we had over 500,000 people hospitalized. Then we discovered that is not the best way to treat mental illness. If you put someone in an institution and leave them there for a long time that person will become institutionalized, and it becomes difficult for them to live on the outside, even if their mental illness remediates.
So in the 1950s and ’60s a public policy decision was made to deinstitutionalize. It was the right policy, but it wasn’t implemented correctly. It requires flexible home- and community-based care, so that when patients are discharged they go home not to minimalistic care, but to creative, energetic services that are available as needed. That might include somebody coming by the house and helping out, or coming by late at night for a meds check, or helping with a problem at work. In other words, whatever it takes so that person can live successfully in their community, with a home, a job, and good relationships. That’s what is needed, and it is doable.
But the system we have in place does not provide that. “Healing the Broken Mind” addresses five different components of change that need to occur to get us there.
What are the five components?
The first thing we need to do is to embrace evidence-based practice. The idea is to offer treatments that are scientifically proven to help people get better quickly. Embracing an outcome-based system of care means we start measuring how effective we are in the lives of people who come for services. It may sound simple, but it would be transformative to the field of mental health to embrace this concept and run with it.
The second thing we need is to break the state monopoly on public sector psychiatric care, which is the system that cares for most of the people with serious mental illness. We need to inject the private sector competitive work environment into the public sector mental health system.
The third thing is to work for parity coverage. People with mental illness should get the same amount of coverage received by people with medical-surgical needs. A federal law was passed last year that will greatly advance this cause, but it’s yet to be implemented and implementation is going to be a challenge.
The fourth point is to develop a consumer-focused system, where those who are being treated are invited to collaborate with the caregiver. In other words, the provider sits down with the patient to discuss the relative advantages and disadvantages of the treatment options to get feedback and figure out what his or her preferences are. In the mental health system—as well as the health care system—the best care is delivered when the physician collaborates with the patient.
The last point concerns overcoming resistance to change. A lot of people are saying the same things I say in the book, yet the changes still haven’t happened. The reason is that there is a system in place that spends about a hundred billion dollars a year, so there is a lot of vested interest. People who benefit from the status quo aren’t crazy about the dramatic reforms that I and others are calling for.
So we have to look for an opportunity where there is an economic imperative for change, a political imperative for change, and visionary leadership. We need people who have the courage to stand up and push reforms through, someone like a Ted Kennedy, who unfortunately is no longer with us. My argument is that we need a perfect storm of those three factors in order to overcome resistance to change.
With all the talk about health care reform, there hasn’t been a lot of discussion about mental health care. Why aren’t they considered together?
Myself and others are trying to do that. There are voices on the Hill, like Patrick Kennedy, who is a representative for Rhode Island. He’s introducing mental health components to the health care agenda. But you’re right, there are no towering voices and that’s one of the problems. Mental health care isn’t a sexy topic, there isn’t much of a constituency out there, and it’s pretty hard to build a political career on championing mental health. So there is a need for leadership to step forward on behalf of Americans who struggle with mental illness. All we can do is hope and pray that people will indeed step forward, perhaps in this upcoming cycle of health care reform.
Is there a country that the U.S. can use as a model for reform?
Yes, Australia has done a pretty good job of creating an outcome-oriented system of care. They collect outcome data on a regular basis and it has been very helpful in terms of fine-tuning what works and figuring out what doesn’t.
Some states here in the U.S. have begun implementing similar systems. Virginia started a pilot program under my tenure that led to a focus on clinical outcomes, for instance. So there are efforts being made in that direction.
One of the points I make in my book, though, is that unless we can move ahead on all five fronts we aren’t going to get very far. We are going to end up with basically the same status quo system.
What do you say to critics who claim that the U.S. population is over-medicated on antidepressants and other psychiatric drugs?
I agree. There is a great tendency for us to over-medicate. And one reason is that if you’re a psychiatrist and you’ve got a half-hour to meet with a new patient, and after that, 15 minutes a month, about all you can do is make sure they have enough meds so their symptoms don’t burst through. The trouble is that people go out over-medicated and the side effects get really irritating, so they discontinue care and become non-compliant. It’s a self-defeating system.
How do you feel about journalists who have gone undercover in mental institutions, like Norah Vincent, who wrote the book “Voluntary Madness,” for example?
I’m all for it. To be honest, when I was Commissioner one of my fantasies was to somehow have myself committed [laughs]. I never could figure out a way to do that.
But I’m all for sharing the data that shows what is going on inside the mental health system. Whether that’s length of stay or the amount of medication given for various diagnoses, the more data that is available, the better off everyone will be. Right now there is a great tendency—not only in the mental health system, but in the health system as well—for hospitals and other providers of care to keep information close to the vest.
Earlier you talked about needing a perfect storm to overcome resistance to health care reform. Do you believe now is the time?
With the Obama administration saying now is the time for health care reform, we have a unique opportunity to get it right. For health care to succeed, mental health care needs to succeed too, because it’s a significant subset of health care. The timing is right for there to be genuine, transformative mental health care reform on a national level as part of health care reform.