Virgil reflects on the mental health crisis in America
Updated: Nov 11, 2019
In the following post, I amble through a forest of wisdom I have recently observed in others. While observing their differences I have also seen that most are woven into a common theme: restoring a sense of community, belonging, connectivity, engagement, and relationship. These elements are critically important to the process of healing not only mental and emotional illness and dis-ease, but also the process of healing our planet and our politically divided nation.
My life’s vocational mission has been to help create healing therapeutic communities (nonprofit, residential treatment centers) within which the best of scientific, clinical interventions can be woven and individually aligned to help mentally ill individuals achieve and sustain their highest levels of functioning and fulfillment.
My life’s avocational mission has been to live within and support a loving family where I see our four children and their spouses (Lis and mine) also fulfilling their missions by weaving their own tapestry of healing relationships into their families and communities. As I accompanied some of our grandchildren in their protest of the climate crisis a few days ago, I could see that they, too, are launching their missions. (However, I hope that play and education are still the primary pursuits of our grandchildren at this point.)
Vocationally, my work is not yet over. My ‘retirement’ work (Virgil Stucker and Associates LLC (VSA)) is building a virtual healing community through therapeutic consultation. We help families navigate the mental health system for a loved one and help mental health leaders launch and support their own healing communities while also helping them to survive and thrive in their arduous yet fulfilling roles as leaders. This includes shining light on current leaders through our podcast Mental Horizons. Of course, I love that Stephanie, our youngest daughter, is my partner in the new phase of work. I am so proud of her creative leadership and commitment to this new mission.
On my mind is the mental health crisis in America.
Over the last two weeks I have had conversations with psychiatrists who are co-creating solutions through nutrition and new medication combinations. I have also read Mind Fixers - Psychiatry’s Troubled Search for The Biology Mental Illness by Anne Harrington, who helps us not to throw away current biological options even though they may be ‘troubled’. The day after finishing her book, I attended the Austen Riggs Center centennial conference, The Mental Health Crisis in America: Recognizing Problems, Working Toward Solutions (slide presentations from amazing thought leaders are on their website).
There is no narrow, singular mental health solution; in fact, all such approaches are flawed. There is also no genetic solution or perfect pill around the corner.
If we recognize that mental and emotional dis-ease arises from or creates a dis-engagement from one’s relationship with family, community and self, then we can begin to see how an array of mental health care options can be woven together into an individualized plan for improving the process of re-engagement and recovery.
We see the highest levels of re-engagement occur when one’s recovery plan is implemented within the healthy structure of a healing or therapeutic community where they are cared for by family, peers and professional caregivers. This may occur within a residential treatment center or though a comprehensive linkage of ‘outpatient’ services.
I believe that any scientific or clinical intervention that is offered to someone with mental illness will be most successful and have sustained results if it is delivered by someone who is able to maintain an authentically caring relationship with them. This has been verified by research about the impact of the ‘placebo effect’. Within a therapeutic community, this may be known as ‘milieu therapy’.
Recognizing the vulnerability of someone with a mental illness, we need to believe in them even when they may not believe in themselves. Often times we even need to walk with them amidst the noise of their delusions and disbelief and accompany them to the edge of the abyss.
We are ‘present’ to accept their authentic self as it emerges and to support their recovery with our professional mental health interventions and with our love.
As vitality outshines their vulnerability, we co-create plans, goals and structure with the person of concern. A re-connected life meaningfully engaged in community begins to resume.
THE FORMULA FOR A RECOVERY PLAN: TWO QUESTIONS
THE FIRST QUESTION
What are your symptoms (impediments to engagement) and what is your diagnosis?
Clinical interventions are best collaboratively selected individually, not ideologically, from the categories below (not all of them!). Each is aligned with the relevant symptom(s) with the understanding that none is a cure.
Psychopharmacological or biochemical interventions
Standard psychotropic medications for mental health symptoms
Medically assisted treatment (MAT) for substance use disorder
Innovative psychedelic options
Genetic (not yet an intervention except to match medications with metabolism)
Milieu therapy (achieved by engaging in a healing community)
Neuroscience or electromagnetic
Neurofeedback on one end of the invasiveness spectrum with ECT on the other, with TMS in the middle
Nutritional counseling for improved brain health
Five levels of nutritional psychiatry
Ketogenic diet as a medically ‘prescribed’ intervention for improving brain health
Integrative Physical Health Interventions
Exercise routine for brain/body health
Physiological assessment and treatments of physical ailments, which may trigger mental health symptoms
Assessment and treatment of pain, which may be ‘real’ but found to be psychosomatic with no real physical cause.
Complementary modalities such as massage therapy, yoga, Qi Gong for overall wellness, and mindfulness training
Where (from whom) are these Interventions best obtained? Answers to these questions are based on the complexity and acuity of the person and help to clarify where on the continuum of mental health care optimal results can be achieved.
THE SECOND QUESTION
What is your dream?
Over the years I have asked this question of hundreds of individuals; sometimes the response is puzzlement with phrases like “I don’t know, no one has asked me that question for a long time. They more frequently ask, what is my diagnosis?” As I continue this dialogue with them, I have sometimes felt like an archaeologist in search of treasure. Most often a glimpse of a dream emerges and, as it does, the person’s voice grows stronger.
Their answer is expanded through continuing dialogue into core goals and objectives associated with plans for implementation. Therapeutic communities may provide access to work and educational activities as a part of the recovery process to help individuals clarify their dreams and activate their awareness that they can actually lead meaningful and purposeful lives. For those who do not need the residential support of therapeutic communities, a coach or mentor may also be a helpful ‘intervention’ to assist them with meeting goals.
SUSTAINABLE RESULTS FROM THE RECOVERY PLAN
The person experiences, first, a greater sense of belonging in the world,
A restored capacity for maintaining relationships,
A greater sense of purpose and meaning (related to education, work and fulfillment activities), and is
Continuously learning and using skills that will help him or her not to be derailed when symptoms arise again.
The importance of these three attributes of recovery was validated by 10 years of qualitative research in my last therapeutic community CooperRiis. In a recent podcast with Elyn Sacks about her famous life story, she also emphasized the importance of these elements in her own recovery.
Over the last few weeks, at conferences and in various interactions, I have encountered several wise individuals and have been sorting out what I have learned from them. My framework of understanding is the recovery planning ‘formula’ that I have described above. Below is a list of some of those wise individuals.
Chris Palmer, MD at McLean Hospital and Harvard Medical School.
Through our daughter Stephanie McMahon’s podcast with Chris and subsequent conversations with him I have begun to understand that nutritional psychiatry may help the person with mental distress to experience improved well being and a healthier brain. The highest level intervention is the ketogenic diet which literally energizes the brain and calms psychosis for some. Chris’ research and protocols are still in process and we will follow his progress closely. I had no idea that a diet rich in fat could energize your brain and help you lose weight.
Rocco Marotta, MD, at Silver Hill Hospital.
Dr. Marotta strives to help individuals with persistent psychosis. We know that Clozaril can often help, even though it can also be physically harmful. ‘Rocky’ notices also that while it helps to curb active symptoms, the person is still too frequently left inactive, unmotivated and disconnected. He has found that by adding oxytocin (the ‘love’ hormone) and sometimes NuVigil to their regimen that his patients become more active, motivated and connected. I sense that his genuine sense of caring also plays a role! (Please let me know if you would like a copy of his publication of case studies.)
Anne Harrington, professor at Harvard and author of Mind Fixers.
During the last decade my understanding of biological psychiatry was deeply impacted by Robert Whitaker’s Anatomy of an Epidemic, which was published in 2010. It assembled information that criticized and condemned pharmaceutical companies and the use of psychiatric medications… and provided no way forward for people who still found that their personal recovery relied on some use of psychotropic medications. Anne’s book is based on the same information contained in Bob’s but she provides a way forward. She acknowledges that psychiatry and pharmaceutical firms have provided only highly imperfect biological options (not solutions), while helping us to see that these options may still be woven into a person’s plan for recovery… as part of the puzzle, not a cure.
Anne Harrington’s review of both history and contemporary efforts shows there is indeed no singular cure being provided by any practitioner.
She tends toward endorsing the importance of community acceptance and inclusion, which are dear to my heart.
Then comes the Mental Health Crises in America conference at Austen Riggs. I waded into a weekend of conversations with world-class leaders about the “Crisis” and several speakers seemed to zero in on the healing value of therapeutic community.
I heard Carol Gilligan, PhD give the keynote and bought her new book The Crisis in Connection. Peter Fonagy, PhD well-known for his ‘Mentalization’ techniques, flew in from London to give a keynote to us about a core feature of mental illness being “the pervasive absence of trust”.
In multiple conversations during the conference, I began to feel that my life’s work of establishing residential therapeutic communities may have prepared me to add more value to current, emerging ‘connection or relationship building’ efforts to address the Crisis. I was urged to write a book.
Anita Everett, MD, the Director of the Center for Mental Health Services at SAMHSA (and former president of the APA and AACP), who identifies as a ‘community psychiatrist’ said the “majority of people with mental illness rely on Medicaid and Medicare”. Anita is ideally situated in her current director role to have significant impact on the Crisis.
Here are some of her startling observations and facts:
She sees that we are now in the Fourth Era of Recovery and Rapprochement, (a restoration of harmonious relationship?) between those in distress and caregivers, including rethinking how we are using inpatient care.
The First Era of Mental Health Care, Anita describes as the Dark Ages before 1800.
The Second Era of Institutions and Asylums was from 1800-1963.
The Third Era was the Build Up of Community Care, informed largely by President Kennedy’s Community Mental Health Center legislation which he signed in 1963. The full hope of this legation was never fulfilled; hospitals were closed and many mentally iil individuals ended up being homeless or in prison.
Now, the hope of the Fourth Era of Recovery and Rapprochement has emerged in the midst of crisis
The “Front Door Problems” of the mental health crisis in America:
The US had 46 million people with mental illness; 25% of these with serious mental illness.
Of the 46 million, 20% receive treatment
Of the seriously mentally ill, a little more than 50% receive treatment
47,000 die by suicide each year, on par with opioid deaths
Life span in US is shorter now because of these deaths.
The ‘Front Door’ is too often closed because of prolonged waiting periods. There are not enough professionals and not enough use of EMR (electronic medical records) which speeds the making of appointments.
ER departments are still a primary ‘front door’ and they are frequently filled with patents waiting for a bed. Mental Health Crisis Centers are growing in numbers.
The "Black Box"; even when they get beyond the ‘front door’ into the black box of treatment there are many impediments.
A diagnosis is developed but it doesn’t give us much useful information.
Hugh problem with how we formulate a whole picture of a person… check lists don’t work.
Treatment approaches are highly variable. What is the person actually getting? We don’t really know what treatments work best.
Suicide interventions are available but variably and insufficiently used.
The "Back door" - what happens when patients move out of treatment… out of the ‘box'?
Unfortunately, a lot of people drop out of treatment prematurely and 90% of those are at risk of relapse
Also, in the US, when someone is finished with treatment, we generally ‘close their chart’. This is a problem because we seldom follow up and people feel uncared for. This is especially problematic for a person who has made a suicide attempt.
We are learning that follow up after an ER visit for a suicide attempt is very helpful… unfortunately, the follow-up seldom happens.
Anita helped us imagine options. For example, in Australia such a person receives a caring post card… this proactive outreach shows the person that someone cares about them.
I look forward to learning more from Anita about how this kind of caring and connection can be built into the current public mental health system. It would seem that the quality of relationship that the simple post card reflects, for example, is a state of mind that really doesn’t cost much to create.
Here are some pertinent remarks from Jeffrey Geller, MD, Medical Director of the Worcester Recovery Center and President-Elect of the APA (with 39,000 members).
He will begin his presidency in April 2020. Jeffrey has long appreciated the importance of therapeutic communities, which I know of through his love for Gould Farm. He and I had breakfast together at the conference with his friend Carrie Sacco, a nurse who is starting a nonprofit to improve the impact of nutrition on mental health.
Jeffrey told me that one of his main projects for when he is APA President will be to try to help states determine the number of new inpatient beds that are needed. Like Anita, he sees that we need to re-think inpatient beds.
Emergency rooms are filled and we have a shortage of inpatient beds. The method for calculating the number of needed beds is complex.
Jeffrey and Anita are involved with the ‘public mental health system’ at high levels.
At the conference we also heard from local Berkshire County leaders of this system: Colleen Holmes, CEO of Berkshire Children and Families and Christine Macbeth, CEO of the Brien Center. Each expressed concerns about impediments to access; once the ‘front door’ is open only limited treatments are offered by an insufficient workforce. The treatment experience is short and the person is back home or back on the streets too soon. Too frequently, homelessness or jail becomes their un-therapeutic community. Nationally about 600,000 people with mental illness are in jail or prison and about 250,000 are homeless.
During the conference opening Eric Plakun, MD, Austen Riggs director also described the experience for those with private medical insurance who can theoretically access what may be better treatments in the private system when they are experiencing a personal crisis. Too frequently, however, the only care they receive is ‘crisis stabilization’ with no extended support to achieve recovery. Recent court cases described below are improving this.
As therapeutic consultants, our VSA mission is to assist families with a mentally ill member to help their family member develop and pursue a full recovery plan, accessing the entire array of best interventions in the ‘black box’. The conversations at the conference about crises helped me to see even more clearly the importance of our work as hopeful navigators.
Wisdom about suicide
Jane Tillman, Ph.D. is the director of the Erikson Institute at Austen Riggs Center.
We learned from Jane that between 1990-2016 the worldwide suicide rate actually decreased while the rate of suicide in the USA increased more than 30% between 1999-2016. Wow! I did not know that; I knew our suicide rate was increasing in the US, but I thought that it was increasing everywhere. Not so. Here are some telling statistics about suicide in the US:
More than 47,000 people died by suicide in 2017
About 70% of suicide deaths in USA are white males
51% of suicide deaths involve use of a firearm
Rural counties have the highest suicide rates and greatest increase in suicide over time
At the county level: High social fragmentation, an increasing population without health insurance, and an increasing percentage of veterans in a county are associated with a higher suicide rate
Jane named the “Four R’s” as a formula, providing protection against suicide:
Relationship - help people to know that someone cares about them. They are not alone and are not a burden.
Reason for living (sense of purpose)
Resilience (skills and relationships that help to manage adversity)
Restricting access to lethal means of committing suicide
The first three R’s are clear to me; we now see the importance of the fourth one, Restriction: over 50% of suicide deaths involve the use of a firearm; how can we restrict access?
Use of a firearm is lethal in 90% of attempts, compared to overdose which is lethal about 10% of the time
States with stricter gun control laws have fewer suicide deaths
As the number of gun shops in a geographic area increases so do the deaths from suicide in all county types except the most rural
Suicides using a firearm increased 41% between 2006-2017.
Over 60% of firearm deaths in the US are suicides, a fact that is missed in our conversations about mass shootings.
Jane offered two approaches to gun access restriction:
Gun Safety: work with gun sellers and owners to educate about gun safety
Gun Control: limit access to firearm purchases and use Extreme Risk Protection Orders (ERPO)
Jane’s first three R’s are crystal clear and have been a part of my thinking for many years. These resonate with my awareness that the person with a mental health condition needs to be re-engaged in relationships and increase their sense of purpose and reason to live. I think a wise therapist can also help them to learn skills of resilience. I hope our shared efforts to restrict access to guns can be successful.
Tom Insel, MD helped to move the conference attendees “Beyond Magical Thinking” and basically beyond the ideas that we can find singular solutions to mental illness. He is Chair of the Steinberg Institute and co-founder and president of Mindstrong, a health care startup dedicated to developing new technologies to advance the diagnoses and treatment of mental illness. From 2002-2015, Tom served as director of the National Institute of Mental Health where co-lead the NIH BRAIN Initiative. He left NIMH to lead the mental health team at Verily, an Alphabet company focused on improving health care through technology, research and innovation.
Beyond Magical Thinking? Rather than singular solutions, Tom says,
“The solutions are complex combinations of medical (neuro-modulatory), cognitive (skills), social (connections), commitment (purposes) and spiritual (compassion) interventions.”
He described how we could construct the Camelot for Mental Healthcare, which is designed to serve the person and not the payer.
First the Four P’s:
Mental healthcare should be:
Secondly the Four C’s:
Mental healthcare should:
a) integrate with substance use disorder and primary health care,
b) engage schools, families and communities, and
c) provide reimbursement that recruits and retains providers.
While enjoying Tom’s prescriptive ideas at a policy level, his ideas really came to life as he reflected on his residency at the Berkshire Medical Center 45 years ago, when he also helped to start and lived in a local commune. Austen Riggs was known to him at that time because it had started an outpatient clinic at BMC which became the Brien (mental health) Center.
Looking back, Tom said, “We provided good care 45 years ago… what did we do then that we don’t do today?” “Today, increasing deaths is because of a ‘crisis in care’. It is not for lack of treatment, it is for lack fo care.” We have lack of engagement - 60% who need care do not receive it. Of the 40% who are engaged; most still are underserved… others are minimally served… only about 5% really get better.”
Tom reflected on genomics and neuroscience and stated that they are not relevant to the crisis we are in. “It will be 2050 before they become relevant.”
He also told us of his interest in technology-based mental healthcare, which prompted him to start Mindstrong. We learned a bit about the ‘digital phenotyping’ “a multidisciplinary field of science focused on the “moment-by-moment quantification of the individual-level human phenotype in-situ using data from personal digital devices, in particular smartphones.” Tom said, “Today, if you want to know how someone is doing, their phone knows.”
As soon as he regaled us with the potential benefits of the technology-based care through Mindstrong, he seemed to indicate that it, too, seemed to go into the direction of ‘magical thinking’.
As the conversation between Tom, his fellow presenters and the audience rolled forward, we heard “we know what to do, how to care, why aren’t we doing it?” Some said, “We need a civil rights movement for those with mental illness.” Anita reminded us of the Act Up Movement which helped us to solve the AIDS crisis. I began to wonder if we really have a ‘mental healthcare professional community’ which might foster real action to help solve the crisis. Most professionals are trained to provide care one-on-one. Jeffrey pointed out that most mental health professionals are not even trained to know how to work as an effective member in a treatment team.
Movements are launched by those who have the ability to catalyze one-to-many relationships. ‘Movements’ are also a bit chaotic and may feel out-of-control’ to a mental health professional who is trained to keep chaos in control. So what or who is missing? I remembered the role of the ‘community organizer’ from years past. This seems to be the missing person or role in the mental healthcare field. This person would work in the streets, not in the office where most mental healthcare professionals relate with the world and their patients.
Carol Gilligan, Ph.D. American feminist, ethicist, psychologist, and professor at NYU built further on the theme of the need for healing community. I bought her new book, The Crisis of Connection: Roots, Consequences and Solutions. Carol described our Mental Health Crisis as both “a time for danger and for opportunity.” She said,
“Listen to the adolescents. Their democratic voice is a solution to the crisis of connection.”
Eric Plakun, MD, Austen Riggs director and conference host gave us an overview of how the crisis is being addressed from both ‘bottom-up’ initiatives such as litigation as well as ‘top-down’ like the parity law requiring that mental healthcare be on par with physical healthcare and the Affordable Care Act that assures coverage for pre-existing conditions.
Saul Levin, MD, CEO of the American Psychiatric Association with 39,000 members said,
“The pendulum is beginning to swing. I know you are all busy in your practices but we need to DEMAND parity.”
He said that he has helped to build a coalition of not just psychiatrists but of other physicians, family practice docs, etc. who are also pushing for adherence to the parity law. The coalition now represents 545,000 physicians. Washington, D.C. is beginning to listen.
Caroline Reynolds, attorney with Zuckerman Spaeder helped us to understand the very successful lawsuit that is underway and causing medical insurance companies to begin extending greater coverage for recovery-focused care and not just crisis stabilization. She is the primary attorney in the Witt vs. UBH class-action case. The class is over 50,000 adults and adolescents with substance use disorders and/or mental illness who were denied access to residential treatment, intensive outpatient services and general outpatient care by United Behavioral Healthcare (UBH). The class had a total of 67,000 denied claims.
Surprisingly, all members of the class were covered by employer supported medical insurance; in other words, the best of insurance! The legal claims made by the class were based on ERISA regulations, rather than under the Mental Health Parity and Addiction Equity Act. This strategy was devised by Meiram Bendat, JD, Ph.D., both attorney and psychologist, who was a student of Elyn Sacks'. Meiram is president of Psych-Appeal.
Basically, the claim was that UBH breached their ERISA-required fiduciary duty to offer care, prudence and loyalty in the interest of the patient, not of the insurance company, the employer or the provider. Secondly, the class claimed that UBH had wrongfully denied claims because they had not based their denial on generally accepted standards for care. Instead they developed their own standards that were too narrow and influenced too much by the financial cost to the insurance company of providing the coverage.
Caroline Reunolds, the attorney mentioned above, went to court and proved what the Generally Accepted Standards are. Eric Plakun was instrumental in helping to define these standards which are:
Treat the underlying condition, not only current symptoms.
Treat co-occurring conditions.
Treat at the least intensive level of care that is safe and effective.
Err on the side of caution.
Effective treatment includes services to maintain function.
Determine duration based on individual needs.
Take unique needs of children/adolescents into account.
Make the level of care decision based on a multidimensional assessment,
Caroline showed why and where UBH violated every standard by being too narrow. The judge found a significant conflict of interest in UBH’s Profits versus People conflict. This type of conflict can be normal; however, if it is excessive and harms people through guidelines that are overly profit-oriented, then it is not normal. UBH Financial leadership helped to set the narrow guidelines, focusing on shortening length of stay rather than on serving their members.
The class won and the court has ordered UBH to go back and re-do their decisions for covering care. UBH must now use appropriate guidelines; LOCUS CASSI and ASAM will be used by UBH as of January 2020. An appeal is underway, but UBH is already changing its behavior.
What are the lessons learned? Bottom up change can work. Use lawsuits to achieve change. This approach is person-centered and is a way to achieve change even when political will is missing. The court’s equitable powers are broad and flexible.
What are the negatives? ERISA is limited. No damages are available. There are risks of litigation; oftentimes attorneys are not paid. There are also difficulties inherent in class actions, because the class must be homogeneous.
Eric noted that Austen Riggs has a tool kit for appealing denials on its website.