How to Fix the Broken Mental Health System: Ten Crucial Changes

In 1977, Bill Anthony, PhD,¹ wrote, “The mental health system is plagued by poor outcome figures and saddled with inefficient treatment approaches and an irrelevant diagnostic system.” Since the modern version of our mental health system was initiated over 60 years ago, it has grown exponentially and has become more rigid and, ironically, far less responsive to the needs of persons labeled with psychiatric distress and their families despite all the efforts, costs, rules, regulations, and reimbursement strategies applied to reduce psychological distress. At a SAMHSA-sponsored Transformation Grantees meeting in Washington, DC, in 2012, Ron Manderscheid, PhD, said, “Every major advance in the field of mental health in the last 20 years has been inspired, conceived of, and promoted by people with lived experience, starting with recovery and peer support.”

The Foundation for Excellence in Mental Health Care suggests a total redesign from the federal level down to the local level, including a redistribution of the power structure in policies, practices, and programs. We suggest an emphasis on 3 overarching themes:

1. Supports and treatments are most effective when they are designed and implemented in partnership with the people we are trying to help.

2. We need to recognize the important role social determinants play in the development and persistence of psychological distress.

3. Cultural and ethnic diversity should be honored and embraced.

Mental health challenges are complex and unique to each individual, and social determinants play a major factor in their etiology, course, and outcomes. The dominant paradigm at present, which includes the rapid assignment of a diagnosis and quick application for Social Security disability insurance, emphasizes a medical model that places the problem almost entirely within the individual and ignores the contribution of social factors. This narrow medical approach contributes to low morale, discrimination, depression, and a 25-year shortened life expectancy for those with serious mental illness. By de-emphasizing the contributions of such diverse factors as adverse effects of medication, street drugs, smoking, poor nutrition, and demoralization because of povery, this approach has unnecessarily consigned people not only to a shortened life but also to a life sentence of disability, impoverishment, isolation, profound disillusionment, and despair.

We can develop a system that shifts dramatically from doing things to and for people, to working with them in partnerships that promote recovery. Health comes from where we live, learn, work, and play. These critical factors could be markedly improved by capacity building and partnerships that then influence policy, practices, programs, and research. When communities attempt to do this without the full partnership of the people they are trying to help, their attempts to “fix” the problem are always less effective and at times are harmful, further compounding rather than solving the original problem.

We propose the following immediate changes derived from persons with lived experiences and practice-based evidence to fix the mental health system.

1 The guiding principle for allcare should be “People First.” This means starting with experiences of positive relationships, setting personal goals, learning new skills, developing hope, and taking responsibility for one’s own choices and behaviors. This profound shift in our framework that creates a person-centered approach to care can be implemented immediately and with no extra infusion of resources.

In each community mental health center across the country, we can examine every program, every policy, and every clinical decision and ask, “Are we doing this with the person or to the person? Are we thinking about this problem and responding from the perspective of the person who is experiencing the distress?” This attitude does not ignore the concerns of the community or family-everyone is met in the same way. This is, however, a shift away from designing programs based on funding streams and silos that depend on diagnoses and care that meets the needs of professional organizations rather than the needs of the people we are meant to serve.

2 Transform current systems of care to a recovery-orientation that is humane, trauma-informed, compassionate, and based on the values of respect, social inclusion, integrity, transparency, and hope. If organizations fail to meet new established standards that support recovery, their funding should be reallocated to those that do, thereby reinvesting savings from services that do not enable recovery and resilience into those interventions that do.

3 Provide more opportunities for people suffering from extreme psychological distress and their families to meet with persons trained in approaches that emphasize a person-centered, needs-adapted approach to care. This would include models such as Emotional CPR (http://www.emotional-cpr.org), Hearing Voices Network (http://www.hearingvoicesusa.org), and Dialogic Practice (http://www. dialogicpractice.net).

4 Address data on the dangers of long-term use of drugs and significantly reduce the use of high-dose, polypharmacy practices and the long-term overuse of psychiatric medications. Conduct further research to better understand optimal pharmacotherapy. Consider which patients may be effectively treated with short-term medications and which are likely to recover without them.

5 Increase education in and access to good nutrition and opportunities for exercise. Provide prevention and awareness of the hazards of nicotine, alcohol, and other substances and provide access to care for those who abuse them.

6 Develop more programs that divert persons with mental health challenges and substance abuse disorders from jail. Use programs such as Iron Tribe (http://www.irontribenetwork.org) to provide peer support, housing, and training opportunities.

7 Increase support and education for families and new parents. This should include providing early childhood education, such as Family Building Blocks (http://www.familybuildingblocks.org) and Head Start (http://www.acf.hhs.gov/programs/ohs); offering access to solid, safe, and engaged adults; creating secure attachments for infants and toddlers; and helping young parents break generational vulnerabilities. Provide key support for junior high school, high school, and college-age youths who are struggling with mental health and/or substance use issues.

8 Engage with the media to create a series of public health campaigns specifically targeted to reduce discrimination, and educate the public regarding the dangers of long-term use of psychiatric medications and cost-effective use of evidence-based practices that promote recovery, resilience, and early intervention.

In addition, ask the media to highlight more stories of successful people who are making contributions to society while dealing with mental health challenges. Create a major national marketing campaign around supporting each other’s mental health and partner with the media to show the value of private philanthropy; emphasize the importance of its role in helping to create change. The Foundation for Excellence in Mental Health Care (www.mentalhealthexcellence.org) is leading a community change process designed to engage private philanthropy for the purpose of improving mental health care.

9 Provide funding for supported education and employment to help distressed persons finish their education and get to work so that they can find purpose and meaning in their lives and have avenues to make contributions to their communities. Create safe housing opportunities for peersons with mental health challenges. Provide supported housing, peer supports, and training opportunities for military veterans and their families.

10 Convene national meetings with key peer leaders and national mental health leaders to articulate a recovery-oriented system of supports and services followed by:

• Peer-facilitated local meetings to define what the articulated vision means locally

• Review of the funding levels for all types of services in both the private and public systems together with people who have lived experience to determine whether it is an effective service and whether the funding levels are adequate

• Creation of a strategic plan with outcome measures for changing policy, financing, and governance of the new service system and end policies that protect services not based on unbiased information about short-term and long-term effectiveness

• Appointment of an oversight council of national and local leaders to monitor and propose changes to the strategic plan in light of the information provided in the learning objectives

• Appointment of a council of peer monitors for each state and community to assess the re-organization of service systems, including changes in funding, and to hold leaders and staff at all levels publicly accountable for reformulating the system at all levels

• Creation of a national learning initiative to get unbiased information and research into the hands of all stakeholders

• Redistribution of research dollars to ensure that adequate funding is devoted to developing and evaluating new pathways to promoting resilience, recovery, and overall health rather than limiting funding to seeking answers that are based solely and narrowly on a brain disease hypothesis

• A commitment to a biopsychosocial model that should be operationalized through providing research funding for all 3 components

Effective and lasting improvement in mental health care will occur when our civil discourse has moved beyond fear and misunderstanding. Public policies need to be improved and practiced at the community level and should be guided by expert leaders inclusive of people with lived experience and by individuals who are willing to engage their philanthropic energy into the change process.

“Join us for dialogue and philanthropic change!”

Disclosures:

Dr Nikkel is President and CEO of the Foundation for Excellence in Mental Health Care based in Wilsonville, Ore. She reports no conflicts of interest concerning the subject matter of this article.

References:

1. Anthony WA. Psychological rehabilitation: a concept in need of a method. Am Psychol. 1977;32:658-662.