I've noticed over the past couple of weeks that you and your allies had renewed your media campaign to undermine the rights of people with mental illnesses, and to suggest to the public that forced treatment is the only kind that will work for large numbers of people. I wonder whether decision by the New Mexico and Maine legislatures to reject involuntary outpatient commitment might be fueling some anxiety on your part that the tide was turning against forced treatment.
We can all agree on the objective: helping people with serious mental illnesses lead stable, productive lives in the community. Beyond medication, that will require stable housing, employment opportunities, and the chance to live, love, and learn with friends and family. Research suggests that these supports yield better results, for individuals and for society. Those states with higher rates of hospital and outpatient don't necessarily produce the best outcomes for people with mental illnesses.
There is a lot of good, hard science available about what works in terms of mental health treatment, but reading your recent article belittling the Consensus Statement on Mental Health Recovery from the federal Substance Abuse and Mental Health Services Administration “A Statement of Madness,” National Review Online, April 5, 2006, I was convinced thought I had arrived in the Land of Oz.
Why? Because, in oversimplifying mental illnesses and SAMHSA's response, you constructed a straw man with no brain, no heart and no courage. That's why knocking him over was so incredibly easy. But your criticism gets us no closer to a solution for the many poor people in this country who rely on the public mental health system for the services and supports they need to succeed in the community.
No Brain. Your article revives that old canard about half the people with psychotic disorders lacking “insight” into their illnesses. I've never understood where you found that statistic, or how you can insist on its validity given the remarkable success of programs like Pathways to Housing see www.pathwaystohousing.org and the so-called “AB 34” programs in California see www.ab34.org, that are successfully engaging “the most severely disabled” (to use your term) people with mental illnesses. Employing the very conservative principles of self-direction, empowerment and personal responsibility that you deride in the Consensus Statement, these programs are producing much better outcomes than those that feature compulsory medication. The recovery model is alive and well in this country; you would do well to acknowledge its successes.
No Heart. You were appointed to the Advisory Council for the Center for Mental Health Services at SAMHSA by a president who champions “compassionate conservatism,” but your article trashes the “recovery” orientation of his New Freedom Commission on Mental Health. What would you recommend in its place? Your published writings suggest you favor a broad spectrum of programs that involve involuntary treatment, including court orders for outpatient commitment, mental health courts and other forms of “leverage” to overcome the “treatment resistance” of people with severe and persistent mental illnesses. In your willingness to inject coercion into mental health treatment, you ignore the creative ways in which mobile outreach and assertive community treatment (ACT) are being coupled with supportive housing to yield good life outcomes without force.
No Courage. The seminal contribution of the New Freedom Commission was its articulation of an unspoken truth: “millions of dollars are spent unproductively in a dysfunctional service system that cannot deliver the treatments that work....” [see http://www.mentalhealthcommission.gov/reports/Final_Interim_Reportdoc ]. We can't---as your article advocates---reduce mental health to the question of whether someone “takes his medications.” But we've tried it your way, and it doesn't work. Thinking people realize that real mental health depends on a broad array of personal relationships, personal strengths and professional support. Any new vision of public mental health will upset some apple carts. And I understand how unsettling it must be to you, as a psychiatrist, to be faced with a paradigm shift that reduces the role of medical experts in the field of mental health. We all need to display more courage in our willingness to look at new treatment modalities that might actually work better.
Americans are hungry for new approaches to government programs. In areas like public education, conservatives have championed school vouchers, arguing that it is important to put purchasing power in the hands of the consumer. This, they point out, would have the salutary market effect of improving good schools and driving bad ones to reform or fail. Putting mental health dollars and decision making in the hands of people with mental illnesses makes the same good public policy sense, and SAMHSA's Consensus Statement on Recovery sensibly recognizes that.
Sally, I invite you to join us in building a public mental health system that is as good as the American people it is meant to serve. We're not in Kansas anymore. We're perched on the edge of a new world, and a new vision of public mental health.
Senior Staff Attorney
Bazelon Center for Mental Health Law
1101 15th Street, NW, Suite 1212
Washington, DC 20005-5002
E-mail: michaela @ bazelon.org
Link to Sally Satel's article, "A Statement of Madness,” criticizing the SAMHSA Consensus Statement on Mental Health Recovery (National Review Online, April 5, 2006)