The State of Mental Health Care in the US

Has been, is, and will likely remain, shitty.

There have been a number of movements to get insurance plans to cover medication and therapy visits for insured members to the same degree as any other chronic condition, with mixed success. However, it's fair to say that there has been and continues to be progress on those fronts.

But uninsured people in the US are fucked.

For the most part mental illness isn't going to trigger the acute threat to life and limb that is the standard for care by the Medicaid stopgap. I refuse to call it a system. It's a series of interlocking programs with at least as many loopholes as coverage points, and tends to chronically fail anyone who doesn't meet certain, simple and obvious criteria. For that matter, I've not been all that impressed by the care available in so-called universal health care nations once mental illness gets thrown into the picture. I am specifically criticizing the US situation, but I don't believe that there's a better model extant out there.

Two stories today brought home just how much failure is tolerated by the public, and how little the public understands about chronic mental illness.

The first story is a matter of "Missing White Girl of the Week." It concerns one Zahra Baker, an 11 year old cancer survivor, who was reported missing this past weekend. The police, however feel that there have been no credible reports of the girl for the past month and have already gotten a confession from the step mother, for writing a fraudulent ransom note.

On the face of it, this shouldn't be considered an intersection between mental health and public health concerns.

Until you read the story and see that the neighbors are repeatedly telling reporters that they've seen, and complained, about abusive treatment for the girl from her step mother, in particular, and her father as well. There is an allegation of having had CPS involved with the girl's situation at one point, but no one seems to know what came of that. At this point, ISTM that CPS failed Zahra.

Further, while I don't oppose corporal punishment as a potential tool for parents, I do believe that if you're spanking or beating a child every time that someone visits you, there's a fucking problem there. Further if you're abusing a child, there's a good chance that you're suffering from some form of mental illness yourself for unresolved anger issues.

Because of the stigma associated with mental illness, even people who recognize and admit they have problems legitimately fear what will happen if they seek treatment. Which becomes an additional barrier between people and treatment. With the cost being paid in addiction as people self medicate; misery; death, and even seemingly preventable murders.

Like in the second story I noticed today.

Thomas Cacacie, 26, is confessing to having brutally murdered and raped the 22 yo mother of his son. He has no remorse, and is telling people he believes that Sarah Ann Capps is now in a better place.

The case is bad enough on the face of it. An abused girl and a damaged man get together and continue the cycle of abuse. In spite of having had domestic violence prosecution against Cacacie, Capps still invited him back to live with her after he got out of jail from that.

What's worse are the series of systemic failures that happened to facilitate this tragedy.

Let's begin with Capps being kicked out of her home and sent into foster care after refusing to turn tricks at the Circle K across the street. She was 15 at the time. After that she ended up cycling through fostercare, which is often enough little more than state-sponsored abuse.

A moment here: There are a great number of people involved with the fostercare hodgepodge who are great, loving, sane and admirable people. My gut feeling is that most people involved with fostercare meet that standard. However, it is also my belief that there is a distressingly large fraction of people involved in the system who are abusive; and a smaller but even more disturbing number, who use the system to provide them with sexual gratification. Because of bureaucratic impulses, and the perception that the public won't pay to see the system policed, I believe that these monsters are not being properly weeded out.

This girl ends up latching onto Cacacie as perhaps the one stable point in her whole life. In spite of the violence he shows to her. The story that I've linked does not detail what, if any, mental health treatment she got, but it doesn't take much reading between the lines to estimate that she probably had a number of problems that would qualify for treatment under the mental illness umbrella.

Then there's Cacacie, himself, a heroin addict, who had repeatedly told mental health workers that he fantasized about violently killing Capps. According to the story, even though the workers felt that Cacacie's threats were far more credible than is usual for mental illness patients, they still discharged him.

I have to admit, I have a good deal of sympathy for the workers there in this case. Contrary to what the public may want to believe, most people suffering from mental illness are not threats to others, rather only a threat to themselves. However, one of the major fundamental factors underlying many mental illnesses are unresolved anger issues. It is distressingly common for mental health consumers to talk, often with apparent sincerity, about going out and avenging themselves upon those people whom they believe have done them wrong.

For most of these people, the talk is just that - talk.

Of course, trying to figure out which of the obstreperous patients one is dealing with is an actual threat, instead of just a potential threat, is the sort of thing to give people nightmares. Especially when the public refuses to tolerate mistakes in that judgment.

Which would be a lot easier to protect if the public would admit that not everyone can be stabilized with at most a 30 day stay for inpatient treatment. If the public isn't willing to consider paying for the treatment of someone who is saying the things that Cacacie was saying, on the chance that he might be the one in a hundred whose violent ideations are credible, then this sort of tragedy is set to be repeated.

Of course, whatever blame might be placed at the state of Florida's mental health support, it is dwarfed by Cacacie's own culpability. (In particular, leaving a treatment program in NY to go down to Florida to move in with the person you fantasize about murdering is not what I'd call a smart move.)

Quote:

---

Originally posted by Thomas Cacacie

"I know I'm not going to die a junkie," he said. "For the rest of my life, the taxpayers are going to pay everything for me."

---

Personally, I suspect that even inpatient mental health care would be cheaper than his prison care will be.

I've had bad experiences with mental health care, so I'm pretty soured on it in general. Additionally, the entire philosophical approach to it when it comes to criminal matters is all wrong and probably does more harm than good.

This part you talk about here bugs me:

Quote:

---

Then there's Cacacie, himself, a heroin addict, who had repeatedly told mental health workers that he fantasized about violently killing Capps. According to the story, even though the workers felt that Cacacie's threats were far more credible than is usual for mental illness patients, they still discharged him.

---

Now, as you said, most people suffering from mental illness are not a threat to others. However, the thing that people do not get, time and time again, is that if you are mentally ill it is your mind itself that is being effected by your illness. If threats seem credible from someone who is mentally ill, they need to be taken seriously. Even if those threats are being expressed as something he doesn't want to do, or being expressed without malice. In fact, especially then. If I have the flu, I may be trying my damnedest not to puke, but I'm not in complete control and it may happen anyway.

There really needs to be a better system in this country for helping people with mental illness. Institutions for anyone and everyone with any sort of disability were not the answer, but neither is ignoring them except when they try to kill themselves or commit a crime.

Peeta, I agree with you completely. It's often the arbitrary limit on funding that dictates who will and won't be kept for longer treatment. I'm certainly not au fait with Florida's Medicaid standards for mental health treatment, but things I've heard suggest that they've got a 30 day limit for their patients. Which can be a helpful stay for people in acute distress; it is often less than useful for long term treatment for people with chronic problems that have left them unable to deal with independent living for large periods of time.

And with funding set the way it is, the providers are facing a double triage situation: First off, preference is going to be given to those patients that they believe they can aid with a short stay; then for their limited number of long-term places held, which long term sufferer will get treated? Unless and until treatment funding goes up, it's going to remain a crap shoot.

As for your concerns about mental health care in general, I agree there, too. What we have now is often better than nothing, and to be honest, many of the medications available now are miraculous in their effect. But medication alone does not deal with the patterns of behavior that are set up while in mental illness, even when the original illness is controlled completely by medication. Medication should be matched to therapy, and often finding the right therapist is such a crap shoot, even in those cases where funding is available for that.

Which ignores that for many people medications don't work.

The brain remains the most mysterious organ in the body, and the least understood. At least the interface between the physical brain, and the mind generated by that brain. That the affect each other is obvious, the mechanisms for feedback both ways are so varied and often idiosyncratic that a treatment plan that works for one person may make things worse for another.

In my mind, the biggest benefit of advocating to make mental health treatment more accessible, both financially and socially, is that it will allow people with mental illness to be more able to ask for help. Simply knowing one isn't alone fighting the monsters inside one's head is often worth more than any bottles of miraculous drugs.

Quote:

---

Originally posted by OtakuLoki

The brain remains the most mysterious organ in the body, and the least understood. At least the interface between the physical brain, and the mind generated by that brain. That the affect each other is obvious, the mechanisms for feedback both ways are so varied and often idiosyncratic that a treatment plan that works for one person may make things worse for another.

---

Good point and one that isn't often acknowledged by the public. The news reports some new study involving neurology and portray it as uncovering all the secrets of the mind and people assume this is the case, but it isn't. There is actually very little that is entirely understood at this point and it can be difficult to separate the wheat from the chaff when it comes to so-called "breakthroughs" if you're just following things in the popular press.

There are chemical processes to the brain and those chemicals can be altered through medication, but the brain isn't just neural tissue soaking in a pool of chemicals. Patterns of thought and behavior become ingrained, even when the associated--but potentially not causative--chemical imbalance is controlled. Once a stream bed has been cut it takes effort to make the water flow in new channels and the same can be said for the way that the mind works. Therapy in addition to medication can accomplish a lot, but as you alluded the same medications and same therapy may not work for all people, even if they have the same diagnosis.

What it boils down to is that help needs to be available and within the grasp of those who need it, whatever is needed and for as long as it's needed. Not a once size fits all program or brief stays in a hospital during an accute situation. Preventing crime, homelessness, physical illnesses, and just general suffering more than make it worth it.