Mental Health

There is an excellent article in The Guardian by Rachel Aviv, Psychiatry wars: the lawsuit that put psychoanalysis on trial. The author relates the history of an individual with an array of personality disorders. It is not a story with a happy ending, but it does throw some light on practices of psychotherapy and how they have changed over the last century, particularly in regard to psychoanalytic techniques and medication-based therapies. The lawsuit did not resolve the debates over the values of different modalities of treatment, but it did establish a standard for accountability in regard to claims of effectiveness.

Aviv's article got me to reflecting on my own observations of behavioral and mental health issues. I worked in New York as a welfare department caseworker and in San Francisco and Spokane in the Food Stamps program.  In Spokane, in addition to the food stamps eligibility work, I was also often called on to help out in adult protection services. In Las Cruces, New Mexico, I supervised adult in-home care services for the elderly in a city-run senior services program, and later in a guardianship agency. All of those jobs frequently brought me into contact with individuals with behavioral and mental health issues.

When faced with an individual in a crisis involving their mental condition my first effort was often to call on the services of the community mental health agencies.  The test applied at that point by the mental health crisis worker was to determine if the person's state of mind and behavior constituted an imminent threat to self or others. 

I recall one such crisis in Spokane in which one of my food stamp clients threatened to kill himself. Because he seemed very distraught and persistent in his assertions of self harm, I talked the young man into letting me take him in my car to the community mental health center in town.  We were invited into an office for an interview, and when my client was asked about what his problem was he pulled out a switch-blade knife and began waving it around as he talked. I told him that displaying the knife was not going to help improve things and managed to get him to hand over the weapon to me. The interviewer summoned a burly assistant and I was allowed to depart.  I never learned what kind of help the fellow got in the end, but I felt that I had been able to at least initiate an effort to move the situation in the right direction.

More often than not, however, people who seemed to be experiencing a crisis did not pass the imminent harm test. I am reminded, for instance, of the case of an elderly woman who had applied to me to receive food stamps. In addition to experiencing mental and physical health problems, she was living in a chicken coop. Since the mental health agency would not intervene, I made various suggestions about where some emergency services might be had, but she seemed not to have adequate mental resources to explore the possibilities for  assistance, and I was in no position to devote the necessary time to helping in any significant way.

In my work in senior services and guardianship in New Mexico I had somewhat more latitude in getting out of the office setting to serve as an advocate in crisis situations. Social services for the elderly were generally more accessible than for younger people and I made an effort to cultivate relationships with people responsible for providing mental health and medical care. While I thus made an individual effort to perform in a coordinating case management role, the agencies I worked for were not sufficiently invested in that effort to be really effective.

Faced now with epic problems of homelessness, some cities, including Albuquerque, have started to undertake crisis intervention services with teams of workers who go onto the streets, often as an alternative to police intervention. While that strategy seems somewhat promising it likely will not receive the funding needed for real effectiveness, and it is not in any case answering the underlying economic and housing issues. New Mexico is currently also facing the task of rebuilding behavioral health services after the previous Republican governor brought forth baseless allegations of financial improprieties and imposed crippling funding cuts.