Psychiatry and Recovery: Complementary or Competitive

In an earlier blog, Fuller Torrey, MD described the dramatic deterioration of our mental health nonsystem and the resulting torment for the 600,000 severely ill who are either homeless or in prison (or rotating between the two).

There will be general agreement with Dr Torrey that all of us should feel deeply shamed by this and inspired to do something to reverse it. We can also probably agree that the most important single thing we can do for the severely ill is provide them with decent housing.

Consensus beyond this is more difficult to come by. Dr Torrey emphasizes the need for easy access to adequate treatment, the value of medication, and the very occasional resort to court ordered treatment for those in imminent danger of otherwise winding up imprisoned or homeless.

The recovery movement comes at this from another perspective which will be described by Gina Firman Nikkel, PhD, CEO of the Foundation for Excellence in Mental Health Care. I have asked her to indicate where there are differences, but also where she sees possibilities for joint advocacy and for complementary rather than competitive service delivery. Dr Nikkel writes:

The recovery model is a large and inclusive tent with broad areas of common interest but also many different views on specific points, conditioned by very intense differences in how the mental health system has been experienced. For example, a person who has had negative treatment results, or has been forcibly restrained, or has been treated with disrespect by mental health professionals will have a powerfully negative perspective on the imposition of coercive treatment.

In contrast, the family member who has tried unsuccessfully to get their loved one to accept much needed treatment and has helplessly watched them be imprisoned or wandering the streets will view the use of coercion in a radically different way. Everyone, in their own way, wants what's best for people with mental health challenges, but risks and benefits are interpreted through a personal lens.

There is wide agreement that whatever model we are using, it is crucial to provide the financial, housing, employment, education, and social supports necessary for an independent and successful life. We clearly don’t have anything approaching enough of these. There also consensus that the use of alcohol and street drugs interferes with people getting on with their lives and staying out of jails, prisons, and homelessness. For these problems, peer supports that parallel AA and NA are broadly seen as gaps that can be filled by people with “lived experience.”

It is also hard for anyone to deny the role that trauma and adverse childhood events play as major factors that need far more attention and earlier intervention. This is especially so for children living in troubled families and those who experience “adverse childhood events.” Again, no matter the model, whether medical or social, a trauma-informed system of care would go a long way toward healing psychological, social, and even physiological wounds.

We can also find great common ground among advocates on the need for much better medical care for people with severe mental health issues, especially since their life expectancy is about 20 years shorter than for the general population. Aside from providing access, it is important to train medical personnel about special medical problems drug complications (especially obesity), poor diet, heavy smoking, and lack of exercise. These are key issues that need more attention as integrated health systems are created and charged with improving the health of all populations.

There is a great divide in terms of whether services are best offered in traditional psychiatric or recovery settings, but there is still plenty of shared concern that services of any kind are not consistently or widely available. There are a number of community mental health systems that find a combination of the two types of programs complementary and not at all contradictory.

Recovery is the goal of whatever supports or treatments or interventions are available, especially if recovery is viewed as a life lived with friends, success in school, work, and physical health. Many medically oriented leaders, like Dr Stephen Marder of UCLA, have been saying this for some time.

Finally, whether spoken or not, there’s probably a consensus that fighting with each other is largely a waste of resources and energy. It would be a step in the right direction to acknowledge that significant differences exist but that there is a great deal of common ground. I think there also would be agreement that the best research and science on short term and long term outcomes should become the standards by which many of the disagreements should be judged and resolved to the greatest extent possible.

I am grateful to Drs Torrey and Nikkel. It seems clear to me that their common dedication to helping the severely ill far outweighs any specific areas of difference. The point is that one size does not fit all. As the Talmud puts it, "We don’t see things as they are; we see things as we are."

My clinical and research experience and reading of the literature convince me that medication is essential for most people with severe and chronic symptoms. It is equally clear that medication is way overused in many people who don't need it. Anyone who inflexibly and ideologically believes that medication is all good or all bad is seeing only one part of the complex picture and is making recommendations that will sometimes be out of place and cause more harm than good.

The controversial question of coercive treatment also has to be understood in context. The drastic reduction in inpatient and outpatient services has made any psychiatric treatment, voluntary or coercive, very hard to get. It is now far harder to get into a hospital than out of one. Coercive treatment has become rare, usually brief, and provided as a means of avoiding the much greater, more degrading, and longer term coercion that comes with imprisonment.

It made great sense 50 years ago to fight hard against the then common and often unjustified use of psychiatric coercion. But the real fight now is against the much more frequent and much more coercive imprisonment of the severely ill-ten times more of whom are currently in prisons than in hospitals.

Psychiatric Times is leading what may become a very promising discussion on what can be done to fix our broken heath system. We need to collect the widest possible assortment of suggestions and opinions. Please contribute your ideas and experiences here.