Tuesday, January 08, 2013

Some Other Things To Know

The statewide news is full of stories about the mental health system.  Newspapers being what they are, they try to find an individual story that is particularly wrenching, to make it real for the reader.  Different newspapers are picking different stories.

But I know most of them; one is even my case.  It would be easy to dwell on how the newspapers get the individual stories wrong – that this patient is more drug-seeking than mentally ill, or that one has parents who are refusing to allow the specific treatment most likely to work, or this hospital doesn’t understand the IEA law on sending people here.  But that’s rather beside the point, because the stories are essentially true.  The mental health system is being sued to provide better services, and I greatly fear the unintended side effects that always comes from that approach.  Yet it is true that services do not cover the territory.  And as I have said many times, if the people who understand the system are unwilling to make the hard decisions surgically, someone who doesn’t understand the situation will come in and make them with a hatchet..

Conservatives – yeah, I read us in a lot of places around the web – automatically assume, on the basis of anecdotes, gut feelings, and wishful thinking, that this should all be easily solved without spending much more money.  The system should be managed better.  Lots of those people aren’t really that sick. Money is being wasted in la-de-dah services instead of core functions. Why, I knew a guy who pretended he was crazy…Yeah, we saw that movie too. And we’ve heard plenty of those speeches about having a positive attitude and understanding life is hard, because our supervisors tell them to us, to get us through the day.  You don’t get rid of command hallucinations by walking on the sunny side of the street.

You can find anecdotes for each of those excuses, but the problem doesn’t change.  Even if you could bring us to magic-pony land where public mental health is the best-managed system in the country, you aren’t going to get that much value added.  Or, for a different magic, you could have everyone who suffers from a mental illness understand that and want treatment, and be willing to endure twice the misery and three times the temptation you do to not use drugs, and have completely nonpathological friends and family who are also generous and patient.  And even with all that, there are still going to be holes.

Here are the reasons:  Treatment is very expensive.  Taxpayers prefer to pay for services which benefit many people a little, rather than a few people a lot.  Highways, police departments, schools, parks. Lobbyists who represent small groups tend to work under the radar, trying to get things slipped in to legislation.  Lobbyists representing large groups like to go public, showing their muscle.

Legally, it’s messy.  If you want laws that make people with certain diagnoses have to do things, then you are going to suddenly be making a lot of people do things.  Get that law in place and families will herd their daughters and brothers in to make that happen, and your whole client base just grew threefold.  Not going to save money that way.  Plus, you are going to have a lot of false positives, people deprived of their liberties for very poor reasons.  Well, there are countries that do that.  Do we want to be one of them?

What about disability fraud?  We have many more people considered disabled than we used to.  That means lots of them must be cheating, right?  Not necessarily.  What if life really is more complicated, jobs really are more complicated? What if there used to be a world where they weren’t disabled, just marginal, and before that, a world where they weren’t disabled at all.  We don’t have those elevator operator jobs downtown anymore, and we renamed janitors environmental services workers because it really is more complicated than mopping floors now. There aren’t those nice boarding houses where for a small fee widow-ladies would feed you when you got back from the mills, either. A lot of my patients might have gotten by a hundred years ago.

But primarily, out and beyond all these considerations, people don’t understand how complicated cases can get – legally, medically, strategically.  In earlier generations the really difficult ones just got locked away and ignored, or they died, so there’s not much help in trying to get back to the good old days. Drugs of abuse seem to break your brain much worse than the old days – alcohol and opiates tend to ruin your personality, not your thinking, but the new synthetics do very strange things to your ability to process reality. Head trauma may be less common with increased safety, but on the other hand, we pull TBI people back from death and into a more complicated world, so it might be a net loss. Kids end up in wrong systems, families range from godsends to pathological, medications that usually work don’t always or create unendurable side effects.

Adding to this is the impression that liberals give, that funding services at “proper” levels, whatever that is, isn’t really all that expensive – because they always think that if we just fought fewer wars or didn’t give money to rich people or had the right priorities we would have just oodles left over.  We’re already out of money, long since, and this stuff doesn’t come cheap.

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