Tuesday, November 28, 2017

Allies and Enemies in the Fight for Mental Health Reform

 By Nathan Ahlgrim

The Need for Allies

Image courtesy of Wikimedia Commons.
Mental healthcare in the United States is in need of serious reform. Mental healthcare is less accessible than other services, and efforts to repeal the Affordable Care Act could put adequate care out of reach for millions more Americans.

Opposition to mental healthcare reform comes from all sides, with the popular talking points demanding law and order, fiscal responsibility, and moral accountability. Still, the consequences of un- or under-treated people interacting with un- or under-trained authorities are hard to ignore, most strikingly in the criminal justice system. Americans with mental illnesses are sixteen times more likely to be shot by police, and more than half of all inmates in America suffer from mental health problems. Mental health reform, then, stands to benefit the healthcare system, criminal justice, and family structure itself.

Given the opposition, legislative policy victories will require a rallying of the troops and solidarity among all conceivable allies. Though it is tempting to welcome any and all help, even the purest of idealists can be hamstrung by allying with activists who actively fight the mainstream. The decisions of who to include and exclude as allies can determine a movement’s success as much as the message itself.

Patch Adams

Image courtesy of Wikimedia Commons.
I recently returned from a week of volunteering at the Gesundheit! Institute (yes, the exclamation point is a part of the name). The brainchild of Dr. Patch Adams (in collaboration with a group of classmates and now ex-wife Linda Edquist), the institute was established on the dream of providing free, personal, and caring healthcare as well as a healthcare system that seeks to improve quality of life instead of simply delaying death. Oh, and it is a clinic populated by clowns.

Clowns were and are intimately woven into the fabric of Gesundheit. The Institute was popularized by the sappy and critically derided (but personally cherished) 1998 biopic Patch Adams starring Robin Williams as the clown doctor himself. The movie chronicles Patch’s revolutionary approach to medicine and the opposition he faced to the unorthodoxy of putting the words “clown” and “doctor” in the same job description. In real life, the team operated a free clinic for a renegade twelve-year period, during which they saw more than 15,000 patients. They closed in 1984 to spread the mission, find funding, and build a permanent hospital in West Virginia. As I saw first-hand, the 321-acre land in rural West Virginia is a tangible counterpoint to the American healthcare system. Thirty-three years later, the work is still in progress.

Patch believes in holistic care. Critics often simplify his care philosophy to “laughter cures all.” As jarring as a clown doctor can be, he is far from the only one who takes advantage of laughter therapy. Many nursing homes incorporate deliberate laughter and humor into their care [1, 2], and laughter has been reported to increase psychological resilience and even some physiological measures like pain tolerance [3] and immune activity [4]. Although, not surprisingly, a major weakness in the research linking humor and health is its anecdotal and subjective nature [5, 6]. Patch does believe in laughter as medicine, in conjunction with traditional Western medicine and complementary treatment strategies. In modern parlance, Patch’s philosophy might best be described as promoting wellness above and beyond physical health.

The "Dacha": the main building on the property.
The Gesundheit! Institute grew out of his dissatisfaction with the ineffective and impersonal treatment he received as a patient. And yet, his beliefs about mental health, their causes, and the responsibilities of those struggling with mental health problems can be a hard pill for advocates and allies to swallow.

Conceptualizations of mental illness

Crucially to the matter at hand, Patch dismisses the physiological causes of mental health disorders like depression and attention deficit disorder, going so far as to label those with such illnesses as being morally responsible for their condition (see reactions to speeches here and here). He did release a touching statement following Robin Williams’ tragic suicide, but his primary reaction (relayed by his colleagues) was that “[Robin Williams] did not have any friends.” I cannot defend this position as a neuroscientist and an advocate for those suffering from mental health conditions.

The lens of depression blurs all existing friends until they cease to matter, an effect I have experienced first-hand. Biological mechanisms influence many diseases, and medications can provide relief for many patients. At the same time, I know that over-medicating patients is a real concern, even if a universal consensus seems out of reach. Herein lies the dilemma. Patch offers compassionate care, but disregards the biological basis of mental illnesses. In his mind, lifestyle choices are the principal cause, fault, and blame. His statements are jarring in the current medical context, but the pendulum of mainstream medical opinion has swung erratically between personal responsibility and biomedical etiology of mental illness over the past few centuries. Where the pendulum stops is more than a semantic matter. Everything from treatment outcomes to community acceptance is dependent on how we describe mental health and the people who suffer from related disorders

Stigma

Image courtesy of Pixabay user geralt.
Stigma, as described by Dr. Patrick Corrigan, grows out of the progression from stereotypes (attitudes about groups of people) to prejudice (when you agree with those stereotypes) to discrimination (behavior influenced by prejudice). Potential patients hide from the looming stigma, which can decrease treatment-seeking behavior and kick off a self-perpetuating cycle of isolation [7]. Just how members of the LGBTQ community had to overcome stigma and isolation at the beginning of the gay rights movement, Dr. Corrigan urges people with mental illnesses to “come out” about their status. The only way to decrease stigma is to show that everyone knows someone who is a part of this community.

Should we treat a person as sick or as deficient? I was tempted to champion the biomedical model in the face of Patch’s dismissal. I personally find Patch’s opinion, that mental illnesses like depression are a controllable choice, disrespectful to those suffering from mental illness. It minimizes the biological (and uncontrollable) hurdles that they must overcome. In doing so, his vision of universal healthcare would paradoxically remove necessary treatments from these patients.

Although the National Institute of Mental Health promotes the narrative of biological mechanisms in an effort to mitigate stigma felt by patients (from themselves and others), the net effect of this narrative depends on what sort of stigma is measured. Attributing mental illness to biological mechanisms correlates with decreased social distancing of the person with the illness (i.e. less shunning and shaming), but it also increases how dangerous people with schizophrenia or depression appear [8]. Not only that, but emphasizing the biological cause of a disorder above all other factors is an easy way to breed a perception of helplessness and a lack of control [9]. “Othering” is easy when mental illnesses are confined to a categorically different type of person [9]; however, negating the biology blames the person, causing any mental problem to spring from character flaws and weakness [10]. That is why an integrated biopsychosocial model is indispensable: illnesses are frequently triggered by the environment – be it relationship stress, emotional trauma, or other psychological insult – but the trigger will not spark an illness in the absence of a biological vulnerability (as in the diathesis-stress model [11]). As such, many psychiatrists and neuroscientists now promote an interdisciplinary and holistic view of mental health.

By departing from a holistic approach, figures like Patch can harm the very people I try to advocate for. When this happens, is he still an ally, or does he become an enemy to the cause?

What is doing ‘good’ look like?

The easiest approach would be to identify allies with a simple cost/benefit analysis. Within that framework, Patch’s philanthropy and humanitarian clown tours would land him solidly in the ‘ally’ category. Even so, his opinions can compromise the respect for people with mental health disorders, at a serious cost for those affected.

The communal farmhouse - a place of comfort.
Ultimately, I believe allies are anyone who helps, and Patch helps. According to the caretakers at the Gesundheit! Institute, much of the steady funding for the Institute comes from people with mental illnesses who were helped by Patch and put him in their wills. He does not help everyone, and he may even do some damage along the way, but his good is tangible. To be sure, Patch (and many of those at Gesundheit!) hold unscientific views. I heard everything from the moral model of psychiatric disorders to shamanism and practical magic (the latter two coming from the land managers, not Patch). As a scientist, I do not share those ideas. Even so, I recognize the utility in including everyone who shares the mission to help alleviate the suffering of mental illness as partners.

I loved my time at the Gesundheit! Institute. I truly did. I went to clowning workshops led by an Italian couple who spent their earlier years in a free love commune where they housed “the crazies that the crazy hospital kicked out.” I communally cleaned, ate, gardened, and slept. I connected on a human level in the absence of technology. I was recharged, reenergized, and rejuvenated. Even with objectives and missions so different from mine, I am honored to call them friends, and thankful to call them allies.

References

[1] Ko H-J, Youn C-H. (2011). Geriatrics & Gerontology International 11: 267-74.
[2] Low LF, Goodenough B, Fletcher J, Xu K, Casey AN, Chenoweth L, Fleming R, Spitzer P, Bell JP, Brodaty H. (2014). Journal of the American Medical Directors Association 15: 564-9.
[3] Weisenberg M, Tepper I, Schwarzwald J. (1995). Pain 63: 207-12.
[4] Bennett MP, Zeller JM, Rosenberg L, McCann J. (2003). Alternative Therapies in Health and Medicine 9: 38-45.
[5] McCreaddie M, Wiggins S. (2008). Journal of Advanced Nursing 61: 584-95.
[6] Martin RA. (2001). Psychological bulletin 127: 504-19.
[7] Schomerus G, Angermeyer MC. (2008). Epidemiologia e psichiatria sociale 17: 31-7.
[8] Parcesepe AM, Cabassa LJ. (2013). Administration and policy in mental health 40: 10.1007/s10488-012-0430-z.
[9] Hinshaw SP, Stier A. (2008). Annual Review of Clinical Psychology 4: 367-93.
[10] Feldman DB, Crandall CS. (2007). Journal of Social and Clinical Psychology 26: 137-54.
[11] Salomon K, Jin A. Diathesis-stress model. In: Gellman MD, Turner JR, editors. Encyclopedia of behavioral medicine. New York, NY: Springer New York; 2013. p. 591-2.

Want to cite this post?

Ahlgrim, N. (2017). Allies and Enemies in the Fight for Mental Health Reform. The Neuroethics Blog. Retrieved on , from http://www.theneuroethicsblog.com/2017/11/allies-and-enemies-in-fight-for-mental.html

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