Disaster in Newtown

At the moment I am thinking about mental health services. I just read an article in Mother Jones magazine about how PTSD can actually be contagious in a family. Anger and hyper-awareness and nightmares have been passed on from a returned soldier to his wife and eventually his young daughter. This is well documented in the magazine and is by no means unique.

 I am jumping ahead a bit chronologically to the horrific disaster in Newtown Connecticut in which 20 children ages 6 to 7 and four adults were slaughtered with an automatic rifle wielded by a lone gunman who shot his way into an elementary school and fired indiscriminately at a first grade class and some teachers and principal who tried to protect the children. Many of the children had multiple gunshot wounds. The shooter, of course, committed suicide when the police arrived and as is so often the case he was described as a shy misanthropic loner who was protected by his mother (and the mother was the first victim with six bullet wounds while she was lying in bed). As is so often the case in this scenario, the shooter was ignored by his classmates and peers, thought to be shy, and the parent did not seek help for his angst.

We see this over and over with these massacres. A young person, usually male, who has a history of being "on the outs" with his society and probably very resentful of the fact, works up a rage about his life and life in general and wants to strike out at anything and anybody nearby. Usually the victims are chosen at random and have nothing to do with the reasons for the shooter's rage. Rage can sometimes be manifested in writings as in the case of the Unibomber and the Army psychiatrist at Fort Hood.

Mental health services in this country are in a shambles. There are many reasons for this, but perhaps the most cogent is the attitude of the general public towards psychiatry and its practitioners.  It is often held that mental illness or psychological problems are a sign of a weak person or a person who is "weird", and also that the practice of psychiatry in general is laughable and subject to multiple parodies. Certainly people with serious mental illness such as schizophrenia or paranoia can indeed act "weird" or even sociopathic, and the stigma of this kind of behavior is often generalized to anyone with mental health problems. What's more, from my decades of experience dealing with psychiatrists, I have come to believe that many are ineffectual and sometimes even harmful to their patients. On both coasts, I have seen way too many reputable psychiatrists whose idea of therapy is first to make an official diagnosis (for insurance purposes) and then prescribe medication and see the patient infrequently thereafter. One prestigious psychiatrist with a statewide reputation allegedly responded to a patient's initial request for an appointment by setting up the initial visit at the electroshock therapy room. I have known probably three or four psychiatrists who actually perform psychotherapy and when they do, they are often invaluable. But they are in my experience (and I realize this is selection bias) fairly uncommon to actually rare. Psychiatric social workers, in my experience, have a much better record of actually performing useful and effective therapy, usually using what I have seen and what many experts recommend as the most effective technique: "CBT or Cognitive Behavioral Therapy". It's probably more effective than other more traditional forms of therapy and certainly more so in many cases than formal psychoanalysis. What's more, it's goal oriented and much less cumbersome for both therapist and patient.

An equally severe problem is the fact that mental health therapy is often very poorly reimbursed. Insurance plans, understandably, wish to reimburse activities for which there are tangible results, such as surgery. Psychiatry frequently has vague or muddy outcomes and there has never been, in my opinion, a comprehensive, scientifically sound outcomes-analysis which could be used by insurance companies for purposes of funding. Therefore, the benefits are limited in both amount and time and often ridiculously ineffective. Psychiatry stands near the very bottom of the reimbursement pyramid for medical treatments as does psychiatric social work. For that reason, some people who would be very good at the field decide not to enter it. I worked in a drug rehabilitation facility in California where the needs of addicts extended over several weeks of therapy, often inpatient, for which the reimbursement was 3 to 4 days per year. As I say, I do not blame the insurance companies as they want to see results for their money. Nonetheless, because of the stigma involved, the lack of effective therapists, and the poor reimbursement, good mental health service in this country is uncommon and too often ineffective. I feel very strongly that disasters such as the recent school massacre could have been prevented if this were not the case. But it is. So now what do we do?