MENTAL HEALTH CARE
"... there needs to be less use of force, especially seclusion or
physical restraint."
December 03, 2006
DAVID A. POLLACK
In spite of Oregon's long,
progressive social and health policy tradition, our mental health
system has fallen far and fast in recent years. Economics and
indifference have reversed substantial achievements.
With more than 33 years in the
public mental health system, I am acutely aware -- at both personal
and system levels -- of the destruction. Patients, families,
psychiatric providers and the general public have witnessed repeated
tragedies related to an under-resourced, over-stressed system.
Too often I see patients who
desperately want care denied it because of funding limits, people
jailed who need to be in mental health facilities, families torn up
over their powerlessness to help psychotic adult relatives who
refuse treatment then die from suicide or illness -- but with their
civil rights preserved. Recent Oregonian articles by Michelle
Roberts and Don Colburn highlighted some of the worst problems.
However, increased public
attention, an improving economy and renewed political will can make
our system more effective, efficient and responsive. That
transformation -- being discussed and promoted throughout the public
mental health system -- is reflected in a vision of a revamped
service system that is recovery-oriented, evidence-based and
culturally competent.
Offer recovery options
With appropriate treatment, people
with mental illnesses or substance-use disorders can improve and
live productive and meaningful lives in the community. These
individuals and their families, though, must find more choices,
autonomy and dignity within the treatment system.
Recovery requires active consumer
involvement on the direction and manner of their care and, when they
are healthier, on the care of others and the development and
oversight of policies and programs. Recovery includes educating
patients about their illnesses and providing them skills and
encouragement.
Treatment settings, especially
hospital and residential programs, must be safer. Those facilities
need staff sensitive to the traumatic experiences of many patients,
from involuntary or coercive prior treatment to crossing paths with
the criminal justice system. And within treatment facilities,
there needs to be less use of force, especially seclusion or
physical restraint.
Proven methods work
By basing treatment on proven
methods, not only do people with mental illness improve but overall
costs decrease -- health care costs and societal costs such as
incarceration, social service interventions and lost productivity.
Already there are many established evidence-based,
condition-specific treatments (such as medications, psychotherapy
and skills training) and broader service system approaches (such as
prevention methods, early disease identification, case management
and patient education).
Oregon's 2003 Legislature passed a
landmark bill requiring most public funding for mental health and
addiction services to be evidence based. The state Addiction and
Mental Health Division (AMH) and its community, residential and
hospital partners are expanding evidence-based care (for details:
www.oregon.gov/DHS/mentalhealth/ebp/main.shtml).
A transformed system will integrate
behavioral health into primary care, use proven screening and
treatment guidelines, and share information to better monitor
clinical activities and outcomes.
This initiative provides more
rational and effective treatment for a wide variety of conditions,
ranging from psychotic disorders, drug dependence and the effects of
child abuse.
Hiring the right staff
Health care services must
incorporate the ethnic, religious, racial, gender and other
characteristics that create a person's self -- and world -- view.
Understanding these cultural factors is critical to successfully
improving the system, and can be achieved, in part, by recruiting,
training and retaining diverse workers.
To promote and accomplish these
goals, the state needs to dramatically expand and improve its
behavioral health workforce as it grows. The state hospital system
expansion alone will require more than 400 new psychiatric nurses.
Likewise, community and residential
settings need to enlarge and improve services. Where will such
competent and culturally aware staff come from? How will they be
trained? Participants from all parts of the system, including
academic training programs, the business community, consumers and
advocates, and policy experts must work together to increase the
numbers of motivated, diverse and well-trained staff.
Clearly, the governor, the
Legislature and the people of Oregon need to resuscitate the mental
health budget -- and manage it wisely and fairly. The most
intelligent and responsible way to do this is by creating a
recovery-oriented, evidence-based and culturally competent system.
Dr. David A. Pollack, a
psychiatrist and professor of psychiatry and public health and
preventive medicine at Oregon Health & Science University, was
medical director for the Oregon Office of Mental Health and
Addiction Services from 2002 to 2006, when budget cuts led to the
elimination of his position.
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