I have a neighbor who is riding his bike from Mobile Alabama to Springfield Missouri to call attention to the need for better mental illness care. They happen to have a son who suffers from mental illness and thus (as many of us do) got involved because of their own son and then become involved with an organization that has a much larger purpose. Not only is D. G. riding his bike across country but his wife, Connie, is an officer in the local chapter of NAMI. Part of D.G.’s reason for taking this on, he says, is that

Even if we don’t raise money, if I can change the attitude of just one person relative to mental illness, it’s worth it. We talk about every other disease but we won’t talk about mental illness. There’s just such a terrible stigma associated with it.

Mental illness has been stigmatized since Biblical times. with Descartes being the most recent scapegoat. Part of the stigma was, I suspect, due to the nature of the affliction. Unlike pneumonia with its fever and coughing, those afflicted with mental illness have no outward manifestation, so the common belief seems to be that if they would only try hard enough, they could control their behaviors. In modern times we have devised treatments but the situation has not improved as much as we would hope. Some people don’t respond to the medications. Others may respond partially but feel so fuzzy headed that they want to stop the medication. Others respond so well that they feel normal, so figure they are cured and quit taking the medication for that reason. All in all, not a good illness to have and very difficult to treat, but an illness just like many other chronic illnesses. Because of the need to keep people taking medicine that makes them feel bad even when they are feeling better, mental health professionals developed “Assertive Community Treatment” options that include (from Wikipedia)

  • a clear focus on those participants (clients) who require the most help from the service delivery system;
  • an explicit mission to promote the participants’ independence, rehabilitation, and recovery, and in so doing to prevent homelessness and unnecessary hospitalization;
  • an emphasis on home visits and other in vivo (out-of-the-office) interventions, eliminating the need to transfer learned behaviors from an artificial rehabilitation or treatment setting to the “real world”;
  • a participant-to-staff ratio that is low enough to allow the ACT “core services team” to perform virtually all of the necessary rehabilitation, treatment, and community support tasks themselves in a coordinated and efficient manner—unlike traditional case managers, who broker or “farm out” most of the work to other professionals;
  • a “total team approach” in which all of the staff work with all of the participants, under the supervision of a qualified mental health professional who serves as the team’s leader;
  • an interdisciplinary assessment and service planning process that typically involves a psychiatrist and one or more nurses, occupational therapists, social workers, substance abuse specialists, vocational rehabilitation specialists, and certified peer specialists (individuals who have had personal, successful experience with the recovery process);
  • a willingness on the part of the team to take ultimate professional responsibility for the participants’ well-being in all areas of community functioning, including most especially the “nitty-gritty” aspects of everyday life;
  • a conscious effort to help people avoid crisis situations in the first place or, if that proves impossible, to intervene at any time of the day or night to keep crises from turning into unnecessary hospitalizations; and
  • a promise to work with people on a time-unlimited basis, as long as they demonstrate a continuing need for this highly intensive and integrated form of professional help.

The goal is to maintain the client’s ability to function in society, despite a high cost and potential loss of freedom. If done right, it is expensive. Unfortunately, it is often easier to allow people with mental illness to wander about with no access to care and walk on the other side of the street as we seem to do commonly here in Alabama.

As we fight to destigmatize mental illness and offer appropriate treatment to those who have it, society seems to be moving to stigmatize other folks with certain types of chronic illness. The most recent example is that of diabetes mellitus. I went to a presentation about health coaching at the National Rural Health Association meeting. This presentation discussed a model of care that, although less intensive, offers many elements of Assertive Community Treatment. The goal of the therapy is to move folks with diabetes to a disease-free  state by working with them to encourage lifestyle changes, medication compliance, and disease self-management. It is surprising how rapidly the conversation turns to “disincentives” such as more money in insurance premiums, encouraging “self control” through shame and stigmatization, and “if only they would stay out of McDonald’s.”

As we come to understand how much of our healthcare costs can be reduced through positive lifestyle modifications, I hope that we can celebrate the triumph of modern medicine over the frailty of the human condition. Instead we seem to be moving to punishing those who are less than perfect. A trend I will continue to fight.

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