#451
Title: Within Our Reach: Ending the Mental Health Crisis
Authors: Rosalynn Carter with Susan K. Golant and Kathryn E. Cade
Publisher: Rodale
Year: 2010
193 pages
Received as an advance copy from the publisher.
Rosalynn Carter's most recent book about mental health care in the U.S. provides a useful, broad picture of the relative lack of progress the nation has made in some areas, notably by cutting corners on Kennedy's plan for deinstitutionalization. However, it also suffers from highly problematic omissions.
Carter's overview is good enough to be used as an introductory text for, say, an undergraduate or master's level class in applied psychology, social work, or public policy. However, it paints with a very broad brush and would require active engagement and questioning to be a useful and accurate resource. Carter correctly critiques the relatively brief training in psychology received by medical doctors, but almost completely elides over psychologists, social workers, and other mental health clinicians. As a psychologist, I am dumbfounded by this omission. Psychology and social work are among the mental health professions working assiduously to develop better community-based services that use social, not pharmacological, interventions.
Though psychiatrists are at the top of the allopathic hierarchy, it is ward clerks, milieu counselors and nurses who spend most of the day with patients in a residential or day treatment facility. Treatment teams that include all of the staff who interact therapeutically with clients, and truly value all of their perspectives, will better comprehend clients' experiences and be better situated to act in the clients' best interest. All the more so for treatment teams that include the client in treatment planning. This takes time, money, humility, and service delivery structures that do not give the final word to one person, but to the team. Teamwork is a poor fit with the U.S.'s the increasingly capitalistic and individually-focused culture. There is a larger social critique to be made here, in an era where providing for the welfare of others is blasted as "socialism," which apparently is a bad thing.
I've worked as a trainee, mental health clinician, and psychologist in a reasonable number of public and private mental health facilities. All had their deficiencies and all were situated within a broader cultural context that lacks adequate wrap-around and gap services, and in some cases, even necessary primary care services for poor people or for everyone. However, in every setting there were more dedicated, concerned staff than otherwise. In most we were poorly paid and tangible and intangible benefits were few. Still, the vast majority of social service, psychology, social work, nursing, and medical staff I've known (and I've known a lot through work at the state and educational level as well as on the ground) have been concerned, kind, conscientious workers. This spirit of diligent kindness and service, especially in contexts where even the best effort will fail due to lack of resources, is not reflected in Carter's book.
In those situations where clients and patients have been poorly served, ill-used, and exploited, which certainly also happens with appalling regularity, Carter's main solution seems to be funding. As is well-demonstrated in the literature on infrastructure development, funding is very helpful and a terrific panacea for many problems, but needs to be targeted to the right problems in order to change societal mores, such as stigma.
The book is also overly broad and potentially confusing for lay readers in terms of the individual solution of medication. Carter says, incorrectly, that we now know that the major psychiatric conditions are the result of deficient brain chemistry. This is an overly simplified and inaccurate statement, though it's understandable why she lands there; it is a problem of correlation versus causality. We do not know whether a chemical imbalance causes major psychiatric disorders. If we did, there would be a test of, say, dopamine levels that would accurately predict the presence, absence, or potential for a manifested psychiatric disorder. (This is where Carter's analogy of diabetes reaches its limit--a person with diabetes indeed has a measurable deficit of insulin production or cellular capacity to utilize insulin.) Instead, what we know is that in some proportion of cases, by no means all, of a given disorder (e.g., depression, schizophrenia), some people are helped for a period of time by giving them a medication containing or affecting one or more neurotransmitters, in much larger quantities than would be found naturally in the average brain. We also know that not all medications work for people with the same symptoms, and that some cease to work over time (e.g., "Prozac poop-out"). For that group of people for whom the medication works, we find that it addresses the symptoms. Whether it addresses an underlying biological root problem is not clear. To say it another way, we may not be treating a cause of the disorder. To use an analogy, if I am awake for 36 hours and I'm tired, a cup of coffee might make me less tired and more alert, but it doesn't address the cause of my tiredness. It medicates the symptom.
Carter is very clear on her belief in the utility of medications, and while I'm all for medicine as one option for potentially drastically reducing human suffering, some of the research literature Carter cites is contradicted by other research literature (e.g., there is dispute about the utility of using versus not using medication to treat an initial psychotic episode). In addition, though she touts medication, many of the interventions she praises are systemic and interpersonal, not biochemical. She correctly identifies the diathesis-stressor model of illness/decreased function (though not by that name), noting the concept that some problems require a physiological vulnerability plus an environmental stressor. However, this does not account well for problems of, say, returning veterans. A person can certainly develop PTSD without a head injury or a biological vulnerability to stress. My two cents: Psychiatric disorders, as we currently construe them, probably arise from a variety of causes and have a variety of courses, even if they are manifested by similar constellations of symptoms and signs.
Carter's assertion that the problem is that we know what works and don't speedily implement it has some traction, but not much, since knowing something works in one study doesn't mean it works universally, or even in a second study. On the one hand, it's maddening when lack of funding slows either replication studies or dissemination of viable interventions. On the other hand, I live in a community where there have b3een a number of dangerous cases of mumps and measles because parents didn't vaccinate their children because of Andrew Wakefield's bogus 1998 study "proving" that the MMR vaccination was linked to autism. As MSNBC notes, "vaccination rates have never fully recovered" (http://www.msnbc.msn.com/id/37311056/). Science is slow, and not without its share of unintentional errors and data cooking.
We really need to guard against biological reductionism, which is both inaccurate and obscures interpersonal causes of distress (like child abuse) and societal causes (like poverty or racism). Managed care and the titration of services are largely missing from Carter's book as a targeted and explicitly identified contributor to inadequate services, though from my perspective, this is a major ethical and cultural problem that contributes to lack of services. Again, this primarily but not exclusively affects poor people.
Carter argues for comprehensive services, as do I. This means interventions in addition to or instead of medication, and that requires a shift in the medical paradigm common to the U.S. and Europe. It also requires more attention to the kinds of interpersonal and community interventions that Carter gives as examples, but somehow doesn't attribute sufficiently to psychologists, social workers, and other mental health professionals.
In summary, this is a valuable and potentially useful book, but it has some significant omissions and errors that need to be discussed to make it an accurate tool to effect change.
