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Waves of Change

Waves of Change and Changes of Mind

I have said in other essays that it is at once frightening and amazing to behold the developments in the system of care of the "seriously mentally ill" in the United States in the past forty years. I focus on the past four decades because in 1958 thorazine was synthesized; the first medication in the modern psychiatric arsenal.

Since that time the mental health system has promoted ideas in waves, lapping up against the shores of the communities that comprise our nation.

The first wave was "deinstitutionalization", signed into law in the early 1960's. With the advent of thorazine, persons with "serious mental illness" were no longer in need of warehousing and were sent into communities by the thousands. Deinstitutionalization was thought to be an enlightened and humane measure; one that had the nice systemic side-effect of being cost-effective as well.

The network of Community Mental Health Centers sprang up to provide services to folks who had, until that point, spent their lives in institutions, and the dream was of a new generation of persons with "mental illness" who would never see the inside of a hospital, due to a new generation of improved and better tolerated medications. Deinstitutionalization had some very good results. It also had some very bad results in the form of being blamed for an increase in the number of homeless persons who failed, through no fault of their own, to make the transition back to community life. And, more recently, it is being blamed for violence. Both arguments are popular, and neither are born out by facts.

Deinstitutionalization begat the second wave: case management.

Case managers are mental health workers whose primary responsibility is to broker adjunctive services and provide personal support to persons with "serious mental illness". Case management started as a well-intentioned project in a few states to provide "guides" in the form of a caring human being to persons who were in transition from living in institutions to living in community settings.

Case management became widespread through the community-based mental health system, becoming more and more focused on legitimizing itself as a discreet and necessary discipline within the mental health field and, in the past decade, more and more heavily relied upon as a source of income through Medicare, Medicaid, and private insurance billing in order to sustain the mental health system. Case management was also thought, perhaps, to have the potential to ameliorate the problem of homelessness through the development of a personal relationship and the brokering of services.

Case management begat the third wave: rehabilitation.

Personal support for persons living in community-based settings was not enough. "Meaning" was needed, and rehabilitation was seen as the answer. Psychiatric rehabilitation, while almost always in existence, became the focus of renewed interest as the mental health system sought to help persons with "serious mental illness" find "meaning" through socialization. After a few years, the emphasis on rehabilitation evolved into vocational rehabilitation, assisting persons with "mental illness" in finding "meaning" through work.

Unfortunately, psychiatric vocational rehabilitation on the whole failed to assist people in finding meaningful work. More often than not, vocational rehabilitation specialists sprang up who could assist persons in finding work, but not with finding meaning in the menial work often found. The mental health system didn't suffer, however, because returning "seriously mentally ill" people to work was seen as a mark of systemic success, when compared with the "meaning" derived from organized social activities.

Rehabilitation begat the fourth wave: recovery.

Since rehabilitation failed to assist persons with "serious mental illness" in finding "meaning" in their lives, recovery is being touted as the new wave of care for persons with "serious mental illness". An idea borrowed from the substance abuse field, recovery is seen as a hopeful development in the system's plan to care for persons with "serious mental illness". Recovery implies restoration, fixing what has been broken, an optimistic return to a former way of being that was, somehow, better than current circumstance.

Recovery, as a model for caring for persons with "mental illness", is what the system hopes to offer right now. Recovery will be institutionalized as the new wave of systemic care.

I think it is time for a major course correction.

When I look at the current mental health system in the U.S., I see the potential for something very powerful. I see the potential for transformation, and I see that, so far, the system has complacently settled for far, far less. We have a system that could, with a different attitude toward its constituency, be a resource for a personal transformative experience for each person who is a service recipient. The system has the tools and the technology to do the work.

Look at what we've got. We have a plethora of medications that can be used judiciously and effectively to limit the occasional suffering experienced by persons who have been labeled as "mentally ill". We have cadres of professionals and paraprofessionals with information on supportive services. We have other personnel who are trained at helping people go through transitions. We have even more personnel who believe that they can assist people in "fixing" what is broken in their lives -- be it employment or other activities of daily living. Why hasn't the system figured out how to use all of these resources to help individuals make meaning from the very experiences that bring them to the system in the first place: the experience of having a "mental illness"?

"Mental illness" is probably the most misunderstood phenomenon in human experience. It is often feared, often reviled, often denied. The word most frequently associated with the experience is "stigma", but this is just mental health specific shaming language for prejudice. The mental health system is as much a victim of its own prejudice as is its constituency, and until someone begins to recognize that the experience of "mental illness" is as much of an opportunity for growth and change and personal development as it is a tragedy and catastrophe and personal disaster, nothing will change.

What is required is a complete reframing of the experience of having and living with what is called "mental illness".

Becoming more scientific, labeling it a "brain disorder" and buying further into the western medical model is not going to help. Nor will saying it is a social construct that doesn't, in reality, exist. It is my belief that what is termed "mental illness" does exist, does affect millions of people, and does have the capacity to have a profound influence on people's lives. The quality of that influence is something with which the mental health system could assist, comprised as it is with thousands of trained personnel and funded by millions of public and private dollars.

It is time for a new wave of care -- true care, not institutionalized attempts to bring people into conformity. The ideals to which people with "mental illnesses" are being asked to conform are not based on the experience of living with a "mental illness", they are based on life without "mental Illness", which has, somehow, been assimilated as a better idea. It is time to put the good resources of the comprehensive system to work for each individual, assisting each person who has been labeled with a "mental illness" in finding out for themselves what that means, how that is uniquely expressed through our lives, and what supports and services each person needs to transform the experience from one of grief and loss to one of gain and growth.

It is time for the United States mental health system to change its mind about "mental illness", instead of working to change the minds of persons who have been labeled as "mentally ill".