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New Book Exposes Our Broken Mental Health Care System


Diagnosing American’s Mental Health Failure

The United States, and particularly California, has done a terrible job helping people with mental health problems. California Governor Gavin Newsom’s Prop 1 March ballot measure was the state’s biggest effort to address this crisis ever, and it barely won. People agree there’s a problem but differ on solutions—that’s why Alice Feller’s new book American Madness: Fighting for Patients In A Broken Mental Health System is so valuable.

Feller is a clinical psychiatrist with a long career in the Bay Area. Her book offers a diagnosis for addressing our mental health crisis that should be required reading for those in the Newsom Administration implementing Prop 1.

What distinguishes Feller’s book is her personal experiences that enable readers to clearly understand the failed system. At almost every step of her career—medical school, hospitals, private practice, community clinics and more—she finds systems that fail almost by design. They deny those with acute mental health problems the treatment they need.

Feller highlights three factors interfering with solutions.

Most Need Treatment

First, the mental health care system appears designed to minimize and deter the acute medical treatment those in mental health crisis need. The system empowers those whose medical and psychological problems make them incapable of understanding their needs. So if they don’t take prescribed medication, well, that is their choice.  And if they don’t want to take the drugs necessary to keep them from walking down the street screaming that’s another of “their” choices.

Feller cites progressive advocates who believe that hospitals are as bad for the extremely mentally ill as jails. And that psychiatrists should not be trusted.

When I did media interviews for the Prop 1 campaign I would often say how I thought that the film One Flew Over the Cuckoo’s Nest created a false and damaging stereotype about mental health institutions. Feller reaches the same conclusion.  She breaks down the film, contrasting it with the actual facts upon which it was based—Ken Kesey’s portrait of nurses tormenting patients whose sole “problem” was nonconformity had no basis in reality.

But many progressives see the evil Nurse Ratched stereotype as real today. And so they encourage patients to avoid doctors and the treatment they need.

Wonder why California and the Bay Area has so many people on the street with acute mental health problems? The system is giving them their “freedom.”

A Money Driven Health System

Feller is not the first to bemoan how money drives health care decisions in the United States. But she highlights a pattern of “up-coding” by medical clinics which leads to most if not virtually all patients being diagnosed as “schizophrenic.” Why? That draws the biggest government reimbursement.

Feller shows how the money driven system has even taken over board and care homes. I’ve been an advocate of board and cares since the 1980’s, when Leroy and Kathy Looper ran a home on Guerrero Street in San Francisco (it was known as Chateau Agape and profiled in the New Yorker). I’ve long argued that San Francisco made a huge mistake not subsidizing board and cares, whose decentralized model seems like the best approach for those incapable of independent living.

But Feller shows how corporate chains have taken over board and care’s. And she found none of the caring the Loopers demonstrated for their clients. Board and cares too often become holding cells, with no real treatment involved.

An Unresponsive Bureaucracy

Feller’s account of her efforts in multiple jobs to learn more about patients from others is the third obstacle to success. She tells story after story of losing track of clients who desperately need and would benefit from her care. She is viewed as an outlier by others who have accepted just doing the minimum necessary to get paid.

Feller gives one example of how she tried for months to get email addresses of other doctors so they could connect about patients; she didn’t get the first email until nearly her last day on the job.

Feller left multiple jobs due to a medical care model she recognized was broken. And the sad impact of this broken system is that it drives dedicated and courageous doctors like Alice Feller out. Those willing to continue in these systems must ignore so much bureaucratic nonsense that many of the best people just leave.

Is There Hope?

Feller’s deep dive into what has broken our mental health system does, however, describe what is necessary to improve it. Many of the changes she recommends seem surprisingly easy to do.

Changing billing procedures so that the patient’s actual condition is recorded? Building communication among case managers, doctors, and others involved in the caring process? Accepting that severe mental illness often requires a medical response?

Feller’s American Madness offers a roadmap for fixing our broken mental health system. Anyone interested in securing mental health reforms should read it.

Randy Shaw

Randy Shaw is the Editor of Beyond Chron and the Director of San Francisco’s Tenderloin Housing Clinic, which publishes Beyond Chron. Shaw’s latest book is Generation Priced Out: Who Gets to Live in the New Urban America. He is the author of four prior books on activism, including The Activist’s Handbook: Winning Social Change in the 21st Century, and Beyond the Fields: Cesar Chavez, the UFW and the Struggle for Justice in the 21st Century. He is also the author of The Tenderloin: Sex, Crime and Resistance in the Heart of San Francisco

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