Where we should spend vs. where we spend vs. where we have to spend because we don’t spend where we should.
by DJ Jaffe, author of “Insane Consequences”
1. Where we should spend
- Hospitals. As inpatient capacity goes down, incarceration goes up.
- Housing. It is virtually impossible to help homeless Seriously Mentally Ill (SMI) if they don’t have place to live.
- Assisted Outpatient Treatment. It’s the only program proven nationwide to reduce homelessness, arrest, incarceration, hospitalization in 70% range each in the most seriously mentally ill
- Clubhouses. They provide structured activity, hope, sense of purpose.
- ACT/ICM Case Management. They keep Seriously Mentally Ill (SMI, schizophrenia, bipolar, etc.) connected with doctors, benefits, housing, services that can prevent hospitalization, incarceration, homelessness.
- Psychiatrists. For most SMI, medications are the foundation, and other interventions do not work without this. But they have side-effects and may need constant titrating.
- Rehabilitation. SMI need help regaining lost skills.
- Electroconvulsive Therapy. Often effective for those not helped by other treatments. Works fast, often good for elderly and pregnant moms who can’t tolerate or don’t want meds.*
- Clozapine and injectables. Clozapine reduces suicide. Injectables are long-lasting and increase compliance.*
- Gap Navigators. Hospital, shelter, jail & prison responsibility ends when SMI exit. There must be navigators (case managers) to connect them to ongoing services prior to release.
2. Where we spend.
- Prevention. Serious Mental Illnesses cannot be prevented. There will be a Noble Prize for the scientist who discovers how. We can only prevent those with mental illness from having it become severe and disabling
- Trauma. Trauma is not a mental illness. Everyone experiences something misfortunate. PTSD is a mental illness, and even that runs from mild to severe.
- “At-risk.” Generally a euphemism used to wrap poverty, bad grades, divorce, joblessness in a mental health narrative so mental health funds can be diverted to them. None are mental illnesses or individually risk factors.
- Suicide campaigns. Suicide campaigns do not reduce suicide and are often aimed at non-suicidal, or kids (the least likely to suicide). People over 55 are more high-risk. Targeted interventions are more effective.
- Stigma. Stigma is far behind cost, lack of services, lack of transportation, anosognosia in why people don’t get care
- Mental Health First Aid (MHFA). Evidence is that trained and trainers like it. There is not evidence that mentally ill are helped. Identifying asymptomatic is not problem. Moms of known MI beg for services and can’t get it.
- Public Health Approach. Serious Mental Illness (SMI) is not like AIDS, or sexually transmitted diseases where you can learn how not to become infected.
- Useless Outreach. Outreach should be at exits to jails, shelters, prisons & hospitals where SMI are. Instead, outreach is at elementary schools, shopping centers, and places where SMI are not.
- Antipsychiatry “Peer” Groups & SAMHSA. These groups oppose efforts to focus on and improve care for SMI and promote pop-psychology and non-evidence programs over evidenced based programs (Not all peer groups are antipsychiatry).
3. Where we are forced to spend because we don’t spend where we should.
- Training Police. Police step in after one condition is met: mental health system failed.
- Mental Health Courts. People the mental health system won’t treat go to court where judges order the mental health system to treat them. It’s a long unnecessary round trip.
- Jails and Prisons. Jails and prisons are overwhelmed with mentally ill. Incarcerated have all rights removed and are most likely to commit suicide.
- Forensic Hospitals. Prisons are setting up psychiatric hospitals inside to deal with the lack of them outside.
- Courts, lawyers, DAs. Criminal justice is forced to run a shadow mental health system for those the mental health system refuses to treat.
* Not medical advice. Consult your doctor. (June 2017)
DJ Jaffe is Executive Director of the non-partisan Mental Illness Policy Org., and author of Insane Consequences: How the Mental Health Industry Fails the Mentally Ill. He is a critic of the mental health industry for ignoring the seriously ill, and has been advocating for better treatment for individuals with serious mental illness for over 30 years. He has written op-eds on the intersection of mental health and criminal justice policy for the New York Times, Wall St. Journal and the Washington Post. New York Magazine has credited him with being the driving force behind the passage of New York’s Kendra’s Law and Congress incorporated ideas proposed by DJ in the Helping Families in Mental Health Crisis Act.