How Ronald Reagan caused the hostage situation at Hillary’s headquarters

Several of Hillary Clinton’s campaign workers were held hostage yesterday at her headquarters in Rochester, New Hampshire, and Ronald Reagan bears at least part of the blame.  Richard Kim explains at The Nation – Reagan started to dismantle state-funded mental health care without creating an alternate system, and subsequent administrations have only made the problem worse.

State-funded mental health care wasn’t all that great in many respects, and advocates for the mentally ill supported reform of the large state-run psychiatric hospitals. Reform meant that inpatient institutions, many of which had become abusive warehouses for people the state saw as defective, would be replaced by community-based mental health centers who could provide appropriate, personalized care for those suffering from mental illness while the patients lived at home, with the support of their families.  The advent of effective anti-psychotic drugs made that possible – but that’s not what happened.

What happened is that funding for mental health at every level, public and private, has been consistently reduced over the last 25 years.  No insurance, public or private, covers psychiatric meds or talk therapy at the same level that it covers physical illness.  I’m not saying meds are the solution to everything – far from it – but people with insurance can access medications far more easily than they can talk therapy. For most emotional illnesses (save schizophrenia), talk therapy is just as effective as meds, but it’s far more expensive and insurances just don’t pay for it.

In my area, psychiatrists don’t do therapy any more unless the patient is paying privately. Privately insured patients  can see a therapist (one on their insurance’s panel who is taking new patients) for a limited number of visits with a much higher copay than the one charged for a visit with me. They can more easily access medications, but it can take three or four months to get an appointment with a psychiatrist (one on their insurance’s panel who is taking new patients). And all this is assuming they can acknowledge that psychiatric care and/or therapy might be helpful to them. People with no insurance, or with public insurance like Medicaid, have far fewer choices. And if you have public insurance and don’t speak English? The next available appointment with a Spanish-speaking therapist in my community is usually six months away. If you speak Arabic, or Farsi, or Portuguese, or French? Forget it.

I can’t imagine what yesterday afternoon must have been like for the people in the building, their families, the family of the Leeland Eisenberg, or the police who had to manage the situation. I imagine that they might have nightmares, anxiety, flashbacks and other symptoms. I hope they have better access to mental health care than Mr. Eisenberg did, but thanks to Ronald Reagan I bet they don’t.


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44 Responses to How Ronald Reagan caused the hostage situation at Hillary’s headquarters

  1. Ashley says:

    At least in my state, it seems that Medicaid or Medicare (not sure which one) funds mental health issues pretty well. One of my husband’s friends has been staying with us for a few months, and she suffers from severe depression (multiple suicide attempts, etc.). She’s been on disability for 2 years and ahs her therapy and medicine paid for by Medicaid, all without much hassle from what I’ve seen.

  2. kathygnome says:

    Honestly, while Reagan certain holds blame, there were an equal number of fuzzy headed people from the left who seemed to think deinstitutionalization was more important than where the people were going to go once they were deinstitutionalized. Tossing mentally ill people onto the street was sadly a bipartisan effort.

  3. Hawise says:

    And police stand off involving who knows how many hours of specialized law enforcement services is less costly than dealing with the problem at the outset? There is a real mental divide between effective prevention and last resort measures. The upfront costs are steep but the long term costs of ignoring the problem are an endless chasm.

  4. Marle says:

    Ashley, what state do you live in that your friend’s had little hassle with medicaid and disability? My friend has severe bipolar, and she tried to get on medicaid or disability or anything, and they’ve just been horrible to her. They’ve lost her paperwork several times, one time a social worker she just met told her she was perfectly fine and should go away and get a job, and someone else told her to get pregnant because it would be easier for them to get her on assistance. The only thing she ever got was emergency food stamps, which came six months after she was approved. Nice definition of “emergency” there. She gave up on the system years ago and now she’s uninsured, works odd jobs when she can, and stays with friends and family. After watching her, I have no faith in our welfare system actually helping people.

  5. Quiet Truths says:

    Reagan was the President. The President does not control state-run mental health centers. Nor does he control funding for federal mental health; that would be the responsibility of Congress.

    Reagan WAS the Governor of California. Forty years ago. One suspects that perhaps one or two other individuals in the meantime have made decisions that brought us to our current state.

    If dismantling the mental health care system needs a scapegoat, then kathygnome is quite historically accurate. It was liberals and leftists who were agitating to dismantle the system in the 1960s and 1970s, liberals and leftists who talked about the repressive psychiatric establishment, liberals and leftists who wanted to tear down the medical-industrial complex.

    You’re blaming Reagan for the successful implementation of your own side’s advocacy.

  6. Please says:

    Jay, you can do better than this. Seriously. You discredit your cause by blaming the most attenuated things on people you disagree with. Not to mention the blame for this lies more squarely (though still very attenuated) on liberals who tried to “reform” our mental health systems.

  7. Hawise says:

    No, I blame Reagan era politics for the successful implementation of the cost-reduction side of the advocacy. The whole idea was never implemented. Reduce long-term care institutions that are prone to abuses (they still exist for some vulnerable members of society and they only work to keep people institutionalized) and replace it with local care facilities that bring people back into society, often as tax paying, working members. The reduce happened with the chucking out of people onto the streets without support. The replacing was never done as it required the sort off communal effort that a ‘trickle down’ philosophy can never accomplish.

  8. Pingback: mental health care makes all the difference « One Jewish Dyke

  9. Em says:

    No, no, no, NO. Some people need meds. Some people need therapy. Some need both. It is flat out inaccurate to claim that most people wouldn’t need meds if they only had access to therapy. I am extremely pro-therapy. I think pretty much anyone can benefit from it, and I’m in favor of it being tried before meds whenever possible. But that does not change the fact that in many cases meds are necessary. This is not an either/or situation.

    Also, psychiatrists prescribe meds. Psychologists and social workers provide the bulk of talk therapy.

  10. Jay says:

    Unfortunately for your certainty, Em, the literature is pretty clear about this. For affective disorders (depression and anxiety), long-term results are the same for meds and talk therapy. Meds often work faster, but relapse may be more frequenent. My experience – which is supported by the evidence in the literature – is that many people benefit from a combined approach with meds and therapy. I’m not the one who made it either/or, so stop yelling at me. To have to choose between them – and trust me, people have to choose – based on what benefits the insurance company is lousy care.

    And your other assertion about what psychiatrists do is true now, but is in large part the result of reimbursement patterns. Psychiatrists used to be trained – many still are – to do talk therapy. But psychiatrists are more expensive, so “the market” prefers to have psychologists and social workers (and RNs and EdDs and MFCCs and pastoral counselors) do the majority of therapy. Again, we’re allowed the insurance companies to dictate what care people get.

    To bring in the evidence again (how annoying), the best predictor of effective therapy is the fit between therapist and client. What this means in practice is that some people need to see a number of therapists before they find the right one. If your insurance only allows six therapy visits annually for any one diagnosis, that gets much more difficult.

  11. Jay says:

    To repeat what Hawise said, because Please just didn’t get it, liberals supported the dismantling of the abusive, centralized state hospital system – not the systematic defunding of the public mental health system. The original, liberal, proposal was that the state hospitals would be closed or at least scaled back, and the money saved would be directed to the establishment of community mental health centers to create wider access to treatment. Liberal (read: humane) concerns about the state system as it existed in the 60s were valid; people were condemned essentially to prison, sometimes forcibly sterilized, and subjected to any number of other abuses.

    I’m not suggesting that we should have left the system as it was. I am saying that by accepting the rightwing formulation that the government isn’t responsible for helping those among us who can’t help themselves, we’ve allowed an entire generation to be as lost as those who were shut away in the hospitals.

    Again, I hate to disrupt ideological certainty with actual information, but it was Reagan as governor of California – and his policies as president of the US – who laid the foundation for the system we have now. Did he do it personally? No. Can his political legacy be held accountable? You betcha. George Bush isn’t personally slaughtering Iraqis, but I still hold him culpable for their deaths.

  12. Em says:

    So, talk therapy to someone other than a psychiatrist is market-dictated care. Anyone other than an MD is subpar, okay, got it.

    At what point in someone’s inability to live daily life should they commit to X number of years of therapy before they can function again? Don’t try the meds, kids, just keep plodding along. Someday you’ll be less miserable.

    You are the one who made it either/or in your post and only in your comment clarify that both/and is better than either alone, which is exactly what I said off the bat. Therapy should be available to everyone (look, we agree), but no one should be forced to commit to it long term before they qualify for meds.

    I also see you’ve neglected to mention clinics that offer sliding scales. But then, most of them are staffed with social workers, so I suppose they don’t really count.

  13. Winters Wrath says:

    As I understand it, there’s no reliable evidence suggesting that talk therapy is as effective as medications. Most of the gold-standard studies used combinations of talk therapy, medications, and placebos. What they didn’t use were talk therapy placebos (i.e., just having someone who was not a psychologist talk to a patient about their problems, but allowing the individual).

    The very few studies in the 1950s that did rely on a talk therapy placebo strongly suggested that talk therapy provided by professional psychologists was just as effective as talking to an untrained person identified as a psychologist. Not surprisingly, the APA quickly moved to stifle further research.

  14. Jay says:

    Em, I also said it’s the therapist that counts. I didn’t say psychiatrists were better; all I said was the way things are comes from market forces. Since listening isn’t your aim, though, I guess that doesn’t matter. My previous posts are pretty critical of MDs, but that doesn’t matter either. You can decide to make me what you want, if that suits you. Because of course I never said that someone should have to commit to therapy before trying meds. What I said was that people should be able to choose what works for them without being compelled by the profit motive of the insurance company.

    And I’m not sure how you can paint me both as denying meds to people and as pushing them toward psychiatrists, but whatev.

    There are no clinics that offer sliding scales in my community. I wish there were. And since I have to spell everything out for you or you’ll assume I’m an idiot, let me be as concrete as possible: my ideal model would be a multidisciplinary office where I could work alongside a therapist and a psychiatrist to provide the best care for each of my patients. If that doesn’t fit into your model of me as a narrow-minded bitch, too damn bad.

  15. Mandolin says:

    Em,

    You’re really stretching to read Jay the way you are.

    Jay,

    I’ve had Kaiser most of my life, and have problems with depression most of that time. It’s only now — when I’ve moved to a different state — that I’ve begun being actually able to explore psychoactive medication.

    Kaiser’s great insurance in a number of ways — but I totally agree with your assessment of their ability to handle psychiatric difficulties, which I’m sure is no reflection on the intentions or abilities of the people involved.

  16. Shayne says:

    This is refreshing. To read people who see beneath that veneer of blaming one side or the other. All of the politicians have a hand in it. Saying it’s all so and so’s fault (or even a certain parties fault), is a bad habit used by politicians. I always hoped the people were smarter than that.

  17. Entomologista says:

    Surprise! Spending all that time in graduate and/or professional school does mean we know more than laypeople about our particular area of expertise.

  18. Lorelei says:

    entomologista,

    and spending the majority of your life in the mental health system does mean that we probably know a bit more about the system that you professionals would be too privileged to know about.

  19. Em says:

    I overreacted. I’m sorry.

  20. Hawise says:

    Heck. I’m on board with getting as many people with as many types of expertise involved as possible. My son has needed medication and talk therapy. He has needed social workers and psychologists and he will continue to need to have access to them as he grows and matures. What I would abhor is having someone limit my options who has no clue what my son is going through. My aim is a stable, rational adult at the end of growing up and society has enough ways of screwing up that result without the medical fields helping. Can we stop arguing about who should do the job and start finding ways to get more people involved?

  21. kate says:

    I agree with many here who protest certain points in the post. 1) Liberals did in fact fight to dismantle the horribly unjust system of immediate institutionalization, but like many other well intended programs, the Republicans took the opportunity to put the money saved by the de-commissioning of long term institutions back into their pocket.

    They have done the same with a variety of programs, from the CAP programs of the 60’s, to welfare and anti-poverty initiatives, educational initiatives, on and on. Of course, most people are not informed of these budgetary decisions and the Republicans use the opportunity to point to their opposition and claim, when responsibility for the ensuing mess is demanded, “Well, you wanted it?”

    No, no one wanted seriously paranoid schizophrenics walking the streets with no address, believing that their meds are a fed mind control plot. But its cost effective of course in the Republican mind, because those people usually just end up dying early of disease, exposure or drug and alcohol related problems or suicide.

    What hasn’t been mentioned here is the effect of the Republican stacking of the district and state courts. When someone has to get consideration for disability status in order to get Medicaid and other services, plus cash assistance, one must apply. The usual process is immediate denial, regardless of the quality of the claim. The claimant then has to hire an attorney (of which a cottage industry has developed answering to this need) who will represent them on appeal and usually handle the entire process for those unable to.

    Then one must appear and since the early 90’s, as more conservative judges replace ones from a more liberal time, proving one’s case has become harder and harder. Also, recall that Congress changed the allowances for disability, eliminating alcoholism and drug dependency, ADHD and many other ailments that were seen as prone to increase malingering, were temporary conditions or not of severe enough nature to require a determination of lifelong complete disability.

    Mental illness is not seen as a deserving illness by many in this country and many still see it as a failing of one’s personality and thus, drug therapy is seen as an evil preventive to proper ‘cure’.

    I wasn’t aware that psychiatrists ever did talk therapy, besides Freudian adherents of psychoanalysis, which only the rich can afford anyway. No one spends years of their life searching through ever piece and part of their skeleton closet for the key to happiness.

    Most talk therapy is focused on learning positive life and coping skills in order to facilitate a minimum of functional ability of the client. Drug therapy is often combined with this to assist in helping the patient stabilize to the minimum.

    And it is insulting to anyone who suffers from clearly biologically based illnesses such as schizophrenia, bi-polar disorder or depression. These people cannot talk their brains well and to think so is to insinuate that somehow they are skirting responsibility by not using and maintaining proper medication. In fact, the number of people who know full well that they have such illnesses but due to advanced illness or other over lapping issues, do not maintain.

    That is the real issue, the lack of funding for proper, modern outreach services for the dually diagnosed, semi-independent living patient, who really wants to get better, but due to financial difficulty or short-cuts in even Medicaid funding, cannot access the in-patient services or extensive care they need, not because Republicans want to disfund it either, but because the public refuses to pay for mental health services because they are sickenly ignorant of how important mental health services are.

    I’d also posit that some serious mental health problems do not respond to any treatment, whether talk therapy (which requires a willing participant) or medication, such as personality disorders and sociopaths.

    Schizophrenics and bi-polars often and unfairly get lumped in with the above. There is no excuse, but until it stops, there will no funding, just blaming.

  22. William says:

    No, no, no, NO. Some people need meds. Some people need therapy. Some need both. It is flat out inaccurate to claim that most people wouldn’t need meds if they only had access to therapy. I am extremely pro-therapy. I think pretty much anyone can benefit from it, and I’m in favor of it being tried before meds whenever possible. But that does not change the fact that in many cases meds are necessary. This is not an either/or situation.

    Also, psychiatrists prescribe meds. Psychologists and social workers provide the bulk of talk therapy.

    I’m going to disagree with you on the issue of meds (full disclosure: I’m a doctoral student in psychology). Meds are really only necessary in a handful of disorders with a strong biological base (Bipolar I and II, certain kinds of depression, Schizophrenia, etc). In most other cases, meds are either a band-aid measure or an attempt to save money and time. The problem with medication is that use is strongly tied into the medical model of mental health care that has come to prominence today. As a society, we believe that medicine makes us better, that there must be a pill for everything, that with enough time or research we can cure anything. If a pill exists many people assume (including most doctors) that you can take it and become healthy.

    Sadly, that isn’t the way it works. With mental illness meds might get you out of a crisis, but they aren’t really a solution. Even the best psychotropic medications really only treat symptoms. Taking an antidepressant for depression is like taking a pain killer for a broken bone. Sure, you might not feel the pain anymore, but you haven’t really addressed the problem.

  23. William says:

    I’d also posit that some serious mental health problems do not respond to any treatment, whether talk therapy (which requires a willing participant) or medication, such as personality disorders and sociopaths.

    Schizophrenics and bi-polars often and unfairly get lumped in with the above. There is no excuse, but until it stops, there will no funding, just blaming.

    Umm, what exactly makes you think that people with axis II disorders don’t respond to any treatment? Adler built his career treating Borderline patients. Sure, treading people suffering from personality disorders is a pain in the ass and requires a skilled clinician, but the only Axis II disorder I can think of that no good treatment exists for is Antisocial. Also, before making sweeping generalizations about what can and cannot be treated, do yourself the favor of doing at least enough research to get basic concepts right. “Sociopaths” aren’t a separate class of patients from those with personality disorders, they are individuals who display a certain kind of personality disorder.

    Finally, the reason bipolar patients and schizophrenic patients are so often lumped together is because of similarity and comorbidity. Schizophrenia (in all it’s forms) is a breakdown of the individual and of reality testing, as such it is intimately related personality disorders. Bi-polar disorder has a pretty high rate of comorbidity, and shares patterns of behavior and presentation, with several personality disorders.

    I hate to sound like an ass, but non-experts armchairing these issues is what caused the breakdown of care we saw in this country from when the CMHA passed in 1963 to present.

  24. Mandolin says:

    “Umm, what exactly makes you think that people with axis II disorders don’t respond to any treatment? Adler built his career treating Borderline patients.”

    Many psychiatrists feel this way, so she’s hardly coming out of left field with her opinion.

    “Meds are really only necessary in a handful of disorders with a strong biological base (Bipolar I and II, certain kinds of depression, Schizophrenia, etc). In most other cases, meds are either a band-aid measure or an attempt to save money and time.”

    Many psychiatrists feel this way, so you’re not coming out of left field with your opinion.

    However, I feel both your posts attempt to create your position as one which is uncontested or unconflicted. This is true in neither case. There’s room for disagreement by educated individuals about the role of medication, and the treatability of personality disorders.

  25. Mandolin says:

    “I hate to sound like an ass, but non-experts armchairing these issues is what caused the breakdown of care we saw in this country from when the CMHA passed in 1963 to present.”

    Well, you only sound like an ass to the extent that you assume the rest of us have no familiarity with the psychiatric literature, or with individual psychiatrists who disagree with you for that matter.

  26. asdf says:

    As a patient I can vouch for what William said. I’ve been through a devastating 6 years medically and also socially (not going to get into details) and at one point, when I was 16, was given anti-depressants to combat my depression and OCD symptoms. I tried 2 different kinds over a couple of months and hated both from the first pill (but was urged to try them out anyway); it feels a bit like turning off the faucet to your emotions and sleepwalking through the day. The difference disturbed me to such a degree that I haven’t even considered using them since. I have had doctors suggest anti-depressants since and recoiled each time. Unless you’ve used them first-hand and found they’ve helped you, it would probably be better not to advocate them.

    Just my $0.02

    And yes, I can’t speak for all people but I can definitely speak for myself. And I’m sure there are people out there who really can’t function without some kind of medication. But I agree with William, our society is dangerously over-medicated. It disturbs me that my family doctor gave me a prescription to antidepressants with so little questioning or looking to alternatives first.

  27. Winters Wrath says:

    The problem with medication is that use is strongly tied into the medical model of mental health care that has come to prominence today.

    At least psychiatry’s medical model is evidence-based.

    Here’s some free advice from a Hill staffer who researches health policy for a living: if you want talk therapy to be funded start doing talk therapy placebo studies. The fact that psychology is unwilling — or unable — to prove itself is why Congress refuses to fund it. As liberal as I am, I can’t construct arguments to fund mental health care without that research.

    Unfortunately, those studies’ results may force the psychological community to ask some very uncomfortable questions — especially if the 1950s research is validated.

  28. Hawise says:

    While I agree that we medicate for things very quickly, I have to say that it is a part of the process. The greatest problem appears to be this we are right/no, we are right way of arguing the issue. The truth is probably somewhere in the middle. We need to be more careful about medicating before exploring all options, but we cannot take it off the table because it is a valid option, especially when used with talk therapy.

  29. Ledasmom says:

    We need to be more careful about medicating before exploring all options, but we cannot take it off the table because it is a valid option, especially when used with talk therapy

    Offer me the choice of lesser control of depression with meds only, and better control of depression with meds and talk therapy, and you can bet I’d go for the lesser control and no talk therapy every time. I mean, it’s like a sick joke: Yes, you can get better from your depression – but you have to go and talk to somebody for weeks and try to figure out how not to be depressed! That’s as if you could cure a broken leg by casting it or by whacking it with a stick four times a day, and the second treatment was the preferred one.
    Seems to me that if medication works, it’s the easier and faster option; it makes sense to try medication first. Whenever I get around to doing something regarding the depression, why the hell would I want to try something long and drawn-out first?

  30. Mandolin says:

    “Unless you’ve used them first-hand and found they’ve helped you, it would probably be better not to advocate them.”

    How about: people are different, and what works for them will be different, and they should be given the options of finding out what works for them?

    I swear, this conversation starts to sound like people insisting “I like chicken, therefore YOU MAY NOT HAVE ANY BEEF OR VEGETABLE ENTREES EVER.”

  31. Mandolin says:

    Or, I think Jill’s said occasionally:

    I’m cold, so you put on a sweater.

  32. asdf says:

    “How about: people are different, and what works for them will be different, and they should be given the options of finding out what works for them?”

    Hmm. That is what I was trying to say, but it didn’t come out quite right.

    I also want to point out that my issue with antidepressants has more to do with how easily they are often prescribed than whether or not other people use them. To each their own. I just thought I’d add my own 2 cents to the discussion, oh well ;p

  33. asdf says:

    “How about: people are different, and what works for them will be different, and they should be given the options of finding out what works for them?”

    Hmm. That is what I was trying to say, but it didn’t come out quite right.

    I also want to point out that my issue with antidepressants has more to do with how easily they are often prescribed than whether or not other people use them. To each their own. I just thought I’d add my own 2 cents to the discussion, oh well ;p

  34. Ledasmom says:

    How about: people are different, and what works for them will be different, and they should be given the options of finding out what works for them?

    How the hell are we going to have an argument if you do that? I came here for an argument, you know.

  35. kate says:

    Adler built his career treating Borderline patients.

    Well that’s great that Adler got some borderlines to come into his office and respond to his talk-therapy, I haven’t read his outcomes, but I’d posit that they are mostly anecdote based, mostly relying on self-assessment by the patient or self criticism by the practitioner.

    The nature of a large number of psychological disorders negates the willingness of the sufferer to participate proactively in the process of talk therapy in any of its forms. Then of course there are some PD’s who’d love nothing more than to participate in therapy and make for a good outcome, whatever the clinician decides that might be, say for example, someone with a dependent disorder. What then? Who judges what is a positive outcome?

    Also, before making sweeping generalizations about what can and cannot be treated, do yourself the favor of doing at least enough research to get basic concepts right. “Sociopaths” aren’t a separate class of patients from those with personality disorders, they are individuals who display a certain kind of personality disorder.

    Yes, sociopath as I used the term doesn’t belong in scientific conversation, but I’m not writing a white paper today. My apologies. Sociopathic as many use the term today most closely describes an individual with personality disorder that tends to display in more aggressive, extroverted ways that cause more loss to society and are probably the least responsive to any type of intervention I’d guess than say, a typical borderline.

    Schizophrenia (in all it’s forms) is a breakdown of the individual and of reality testing, as such it is intimately related personality disorders. Bi-polar disorder has a pretty high rate of comorbidity, and shares patterns of behavior and presentation, with several personality disorders.

    Are you saying that schizophrenia is not a brain disease but now is a personality disorder? You’ve got to be kidding! I’d really like to see the research that can conclusively prove that personality disorder can cause brain diseases such as schizophrenia, bi-polar or severe clinical depression.

    I hate to sound like an ass, but non-experts armchairing these issues is what caused the breakdown of care we saw in this country from when the CMHA passed in 1963 to present.

    If the shoe fits….

    You are not only sounding like an ass, but an arrogant one at that. To presume that no one here knows as much about mental illness as you is presumptuous at best.

    The absolution/redemption basis of talk therapy, while on some levels is helpful to people, is justifiably seen as bubkis by many people, especially when asserted as a solution to diseases that respond well to medical treatment.

    It is your profession’s clinging to nineteen century views of mental illness that often holds back progress on mental disease sir.

  36. Mandolin says:

    “To each their own. I just thought I’d add my own 2 cents to the discussion, oh well ;p”

    My caps were overblown. They sounded better in my head. ;) Sorry ’bout that.

  37. exholt says:

    State-funded mental health care wasn’t all that great in many respects,

    That’s putting it mildly. I personally knew someone whose relatives committed her merely for being unconventional during the 1950’s. While she was able to resume a seemingly normal life since then, she has been scarred by her institutionalization experience. By committing her, these relatives of hers behaved no differently from tyrannical Fascist and Communist regimes who used mental institutions as a way to punish and control dissent.

    As for the larger issues of mental health in this country….that defunding was in itself, stark evidence of how mental illness is stigmatized in this and many other societies. We really need to implement the outpatient/hospice care part that was not implemented during the 1980s. The fact mental illness is not treated as a physical illness is disturbing, a signifier of the widespread ignorance of mental illness in our society, and quite unfathomable to me.

  38. A Nony Mouse says:

    Hmmm. Anecdata: I’ve been on meds since 2005 for a trauma that triggered me into PTSD. Thank God for the meds, because it’s taken me two years (so far) to figure out what REALLY triggered the PTSD.

    I’ve been in and out of talk therapy for 25 years, on and off, for treatment of depression and anxiety. Talk therapy is hard work, and emotionally taxing, which is why it has taken me so many years to dig to the bottom of things. I’d go for a couple of years, quit, get to a bad place again, go again, get a little bit “better,” run out of money or insurance, quit, etc.

    I first took meds to treat PPD 6 years ago, and it helped me so much I can’t even describe the feeling of relief. Yes, it “numbed” the feelings somewhat so I could bear to talk about them in therapy. I got to a great place and then the trauma — and now I’m back on meds and in therapy together, and I finally feel like I’m making big progress. And look how much time and care it took!

    I may be on meds for the rest of my life. I don’t know. But I’ll do whatever it takes to keep feeling better than I ever have

    in my whole life.

    (Until the entire health care system breaks down and I can’t afford any more treatment, that is. Currently I pay $800+ per month for our family’s health insurance, which covers things pretty well.)

    And my depression and anxiety aren’t even severe. They’re probably levels at which many of us just live our whole lives.

    I think to advocate one treatment or other for every person is narrow-minded. I feel comfortable offering that opinion even from my comfortable armchair.

    Disclosure: My talk therapy has ALL been with LCSWs and clinical psychologists (some better than others), and my meds are regulated by a psychiatrist.

  39. A Nony Mouse says:

    As an aside, let’s not forget that most people can’t afford my insurance premiums. I can deduct them as a business expense as a self-employed person. Plus I’m middle aged, and when I was in my 20s there was still the opportunity to work hard, buy a house for a reasonable amount of money, live frugally, and be comfortable. If I were in my 20s right now? I’d just be suffering from untreated depression and anxiety.

    And when I started my treatment, let’s not forget that my employer paid 100% of my premiums.

    And I was around when Ronald Reagan took office, and yeah, I DO blame his crappy, “welfare queen,” poverty-sneering policies and the resulting arrogant attitudes of the wealthy for the severely mentally ill homeless people I see every day in my suburb.

  40. William says:

    Many psychiatrists feel this way, so you’re not coming out of left field with your opinion.

    However, I feel both your posts attempt to create your position as one which is uncontested or unconflicted. This is true in neither case. There’s room for disagreement by educated individuals about the role of medication, and the treatability of personality disorders.

    The problem there is that psychiatrists feel that way because psychiatrists don’t have a drug that can easily treat axis II disorder. But psychiatrists don’t really treat patients very often, they do a 15 minute consult and reach for a scrip pad once every month or so. Actual therapy (think kind the person I was responding to said didn’t work for this population) is done by psychologists and masters level clinicians. I don’t really that that there is room for disagreement when it comes to the treatability of Axis II disorders outside of antisocial. Perhaps not every patient will be open to treatment, but simply writing off an entire class of seriously ill people (as Kate seemed to be suggesting) strikes me as downright offensive. Axis II disorders are among the most disruptive and devastating mental illnesses in existence. They are pervasive disorders that a lot of clinicians don’t want to treat because the clients are difficult and often unpleasant. That doesn’t mean they do not deserve care or that they are somehow too horrible to be worthy of care.

    As for my stance on meds, I know theres disagreement, but I still feel that the use of medication as a cure has done more damage to mental health in this country than Reagan’s block grants or JFK’s community mental health centers. The problem with medication is that its expensive, has extremely unpleasant side effects, and only masks the symptoms of disorders that don’t have a strong biological basis. I believe, quite strongly, that medication is a very good tool for crisis intervention and for normalizing life but a very bad tool for long-term symptom management. More importantly, most psychotropics aren’t proscribed by psychiatrists (partly because there aren’t nearly enough psychiatrists in this country if you don’t live in a major city). The numbers vary by study, but somewhere between 60%-80% of psychotropic drug scrips are written by GPs with no specialized training in mental health. Its pretty clear that these doctors are treating mental illness like strep throat or high cholesterol.

  41. William says:

    Well that’s great that Adler got some borderlines to come into his office and respond to his talk-therapy, I haven’t read his outcomes, but I’d posit that they are mostly anecdote based, mostly relying on self-assessment by the patient or self criticism by the practitioner.

    So your stance is that any treatment, regardless of the opinion of the client, practitioner, or general profession community, is assumed to be invalid if it cannot be easily quantified? What standards would you use for assessing treatment of an illness that doesn’t conform to the medical model? More to the point, how would you get around the problems you seem to be forseeing? How do you measure health and illness quantitatively when discussing what is essentially a qualitative issue?

    the nature of a large number of psychological disorders negates the willingness of the sufferer to participate proactively in the process of talk therapy in any of its forms. Then of course there are some PD’s who’d love nothing more than to participate in therapy and make for a good outcome, whatever the clinician decides that might be, say for example, someone with a dependent disorder. What then? Who judges what is a positive outcome?

    I’d say that a positive outcome is a significant reduction of anxiety, reduced dysfunction, improved reality testing, and a reduction in maladaptive behaviors characterized by the patient’s disorder. To use the example of someone with dependent personality disorder, simply cooperation wouldn’t really be what you were looking for. You’d be looking for the client to have less anxiety around being alone or unattached, you’d want to see their valuation of themselves be less linked to others, you’d be looking for a reduction in characteristically dependent behaviors, you’d be looking for increased personal independence. Who would judge these outcomes, well, I’d say the therapist would be a good candidate but you could always have colleagues review session tapes if that wasn’t enough for you. As for client self reports, only an idiot (or a claims adjuster) would give a self-report survey to client and expect to get accurate data.

    Are you saying that schizophrenia is not a brain disease but now is a personality disorder? You’ve got to be kidding! I’d really like to see the research that can conclusively prove that personality disorder can cause brain diseases such as schizophrenia, bi-polar or severe clinical depression.

    Am I saying that schizophrenia isn’t a brain disease but instead a personality disorder? Nope, doesn’t look that way to me. What I was saying was that schizophrenia is related to personality disorders (especially in the public mind) because the presentation is similar. Schizophrenia is a breakdown of the individual. Granted, it has a much more biological basis than PDs, but it would be hard not to see the similarity. Lets put it this way, if you were put in a room with a schizophrenic on a good day and someone with a schizotypal PD, and you had no other data, do you think you’d be able to tell the difference most of the time? Does that mean their illnesses have the same cause? No, of course not. Does that mean that a non-expert might confuse them? Probably.

    If the shoe fits….

    You are not only sounding like an ass, but an arrogant one at that. To presume that no one here knows as much about mental illness as you is presumptuous at best.

    Well, for that I apologize. You’re right, I assumed that you didn’t know what you were talking about. I could defend that assumption pretty well, but that wouldn’t make it any less wrong. I’m sorry for that.

    The absolution/redemption basis of talk therapy, while on some levels is helpful to people, is justifiably seen as bubkis by many people, especially when asserted as a solution to diseases that respond well to medical treatment.

    It is your profession’s clinging to nineteen century views of mental illness that often holds back progress on mental disease sir.

    Well, I do kind of agree with you. I really think that lumping all forms of talk therapy together isn’t a good idea, and that some a much more effective than others. A lot of the talk therapy done today is client centered, and (unless we’re talking about grief counseling) I agree with you that it isn’t a very good treatment for serious illness.

    I really think you and I are talking about two very different things here. You keep mentioning diseases that respond well to medical treatment. I can’t think of too many outside of the ones we’ve already mentioned. For something like schizophrenia, I still think that therapy is very valuable for patients (especially those who don’t have severe cases) who want to eventually get rid of the side-effects that come with even the atypical antipsychotics. Even beyond that goal of getting rid of meds, I think therapy can be valuable in repairing some of the environmental stressors that can aggravate even purely organic illnesses. Still, I can see and accept the other side of the argument there.

    As for the crack about the 19th century, I’ll own that. I’m a disciple of Freud and Jung, and I lean more towards the philosophical roots of psychology than the medical roots. The 20th century theorists that have influenced me come from the existential and the transpersonal branches. I’m fully aware that I’m in the minority in terms of philosophy, but I also feel that someone has to argue against a total transition into the medical model.

  42. Winters Wrath says:

    I really think you and I are talking about two very different things here. You keep mentioning diseases that respond well to medical treatment. I can’t think of too many outside of the ones we’ve already mentioned. For something like schizophrenia, I still think that therapy is very valuable for patients (especially those who don’t have severe cases) who want to eventually get rid of the side-effects that come with even the atypical antipsychotics. Even beyond that goal of getting rid of meds, I think therapy can be valuable in repairing some of the environmental stressors that can aggravate even purely organic illnesses. Still, I can see and accept the other side of the argument there.

    Ask yourself how you’re defining “effective.” When psychologist talk about talk therapy’s efficacy, they’re comparing it to medication. They’re not comparing it to talk therapy placebos — i.e., giving an actor a white coat and telling the patient that the individual is a psychologist. And, like it or not, that’s what I need to have in my hands before I can convince my boss to sponsor mental health bills. (And when I’m talking about sponsoring bills, I’m talking about a post-’08 election in which Democrats control both the Legislative and Executive branches.)

    Further, recent lobbying efforts to increase mental health funding in Africa over the past few years has really shot psychology as a whole in the foot. Why? Because some Congressmen asked the Congressional Research Service to create a report giving us an overview of African psychology institutions and needs. Even though it didn’t directly touch on psychology in America, politicans aren’t as dumb as they look on CNN: they (and their staffs, i.e., me) connected the dots on our own.

    It turns out that medical anthropology’s recent explorations into mental health has really terrible implications for Western psychology. Doctors in a number of nations noted that people would come to see them for some diseasses, but not others — namely depression. Medical anthropologists picked up on this. First, they noticed that the mental health issues faced by individuals in some nations just don’t match the DSM-IV. People who would be locked away in America are considered quirky by Nigerian and Ghanian standards, and quirky people in America would be deemed completely insane over there. (The report described the situation in a number of nations, but I highlight Nigeria and Ghana because most of my friends in law school are from there.)

    Further, anthrpologists noticed that when mentally ill individuals did try to see Western psychologists for talk therapy, talk therapy just didn’t work. The patients just went back to noticed that in a number of cultures, clan and tribal leaders function as psychologists despite having minimal formal training for their positions. Talk therapy just can’t be exported to Ghana and Nigeria the way quinine or AZT can.

    Why can’t talk therapy be exported? Because (1) the conception of self underlying psychology is fatally flawed and ultimately only adequate for Western culture, and (2) talk therapy’s healing power comes primarily from having an individual in a position of cultural authority listen and provide individualized advice to lowly ole’ you. This would also explain why therapist-patient fit is so crucial to talk therapy’s outcome: just as doctor-patient fit was so crucial to medical therapy’s outcome in the eighteenth century.

    Now, it’s entirely possible that these ideas are wrong. But the evidence gathered from other fields is becoming more and more substantial each day. In order to prove medical anthropology’s implications wrong, we’re going to have to see talk therapy trials with placebos.

  43. Jay says:

    therapist-patient fit is so crucial to talk therapy’s outcome: just as doctor-patient fit was so crucial to medical therapy’s outcome in the eighteenth century.

    Doctor-patient fit is still crucial to outcomes, even in the 21st century. (And btw the current biomedical/scientific model of allopathic medicine was developed in the mid-19th century in Germany and not widely accepted in the US until the Flexer report in the early 20th century, so you may want to update your dates a bit if you’re planning to use that analogy again.)

    Back to fit…the patient’s experience of her encounter with the doctor is one of the primary determinants of the patient’s willingness to follow up. In those diseases in which outcomes are determined in part by self-management (arthritis, asthma, diabetes), that kind of “fit” improves outcomes by any measure.

    I think the double-blinded, placebo-controlled trial is over-rated even for straight pharmacology and I’m kind of horrified at the idea of exporting it into other fields. I don’t want Congress to start passing bills mandating what sort of treatment people should have for depression or for diabetes. I want a single-payer health care system that allows for consensus decisions about best practices in both physical and mental health, with enough money to pay people for decent care, and a concerted effort to counter the stigma attached to emotional and mental illness. Far as I can see, the illnesses we’re talking about have both environmental and genetic causes and both neurochemical and behavioral manifestations. And all illness is, ultimately, culturally defined; people in Ghana treat physical illness differently, too – and meds work differently for infection in people with varying beliefs about meds.

    As for the rest of what you say about

  44. Mandolin says:

    “I’m a disciple of Freud and Jung, and I lean more towards the philosophical roots of psychology than the medical roots. ”

    LOL.

    Okay — if that’s your opinion, fine. But you’ve really got to stop pretending that what you say is therefore supported by the bulk of psychological practitioners (or for that matter, the bloody evidence).

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