Peers of the Mental Health Realm

The last decade has seen a flood of peer counselors in the public mental health system in the U.S., the basic idea modeled, if loosely, on the the practice of recovered addicts becoming counselors in the alcohol and other drug (AOD) treatment field.  In mental health it has the added gain of making public mental health treatment a more humane and understanding place.  Psychiatric survivor activists have long called for this move.  If services are provided by counselors who have themselves experienced mental health problems and have been on the receiving end of services, then services will inevitably be rendered in a more sensitive and user-friendly manner.

These things are true as intended, but I feel the need to point out there is also a dark tangled mass of contradictions, uncertainty, and politics that inhabit the practice of peer counseling like a hidden cyst threatening to break open and poison the entire initiative.  As always, I find myself the voice of doom and gloom in the fantasy land of Mental Health where fake positivism, false prophets, and general quackery goes hand in hand with unicorns, pixies, and evidence base practices.

Peer counselors come to the public mental health field like faerie-activists waving their magic "recovery" wands.  They go to the dark places of mental health--think Shutter Island, Sucker Punch, One Who Flew Over the Cuckoo's Nest, and hundred other examples--and these peers turn the dark places into sunlit gardens of recovery with doors broken open to let the sunlight in and to let the inmates out to discover they were never mentally ill to begin with--it was all a lie made up by psychiatry and Big Pharma.

The only thing is, it’s just another lie really.  Let me give you a smattering.

1. Peers do not necessarily have special insight into the experience of individual mental health system users.

Mental health peers are self defined.  It has to be so for simple legal reasons.  A prospective employer is not permitted to ask about an applicant’s disability.  It is contingent upon the applicant to decide if she or he is or is not a mental health peer.

In the AOD field, addiction disorders are a straightforward set of behavioral categories that are bound by a single phenomenon: addiction.  Straightforward, relative to mental health anyway.  By contrast, mental health disorders cover so vast an array of human behavior patterns so as to be absurd.  What does it mean to be a mental health peer?  Does someone who experienced adult attention deficit have some kind of special insight into what it’s like to experience schizophrenia?  Or vice versa?  If that seems like a stretch, it’s because it is.

Imagine, if you will, a world in which medical peers--people who have experienced medical problems and have received medical treatment in their lifetimes--replace nurses in your doctor’s clinic.  Will a medical peer who has experienced medical treatment for eczema have some special understanding, gleaned from experience, into the medical needs of a patient with necrotizing fasciitis?  Sound preposterous?  Why then is the idea of mental health peers any less preposterous?

2. In mental health, recovery is a word without meaning.

One of the basic rationalizations for peer counselors is that a peer is a living example of recovery, a person with a mental health condition who has persevered, and met their therapeutic goals, and now can work productively as a peer counselor.

It stands to reason.  This rationale works very well in AOD services where peer counselors are the norm.  In that field, peer counselors have beat their addiction--they are in recovery--and they can help other addicts on the path to recovery through the wisdom of their experience.

Okay, that’s all well and good.  But.  In the AOD field, recovery is black and white.  You are either using, or you aren’t.  Recovery is tested and assured by urinalysis.

If you think mental health has a standard of recovery, you are mistaken.  Recovery, like the peer identity itself, is entirely self defined.  Anyone, and I mean anyone, can walk through the door and proclaim they are a peer and they are in recovery.  There is no testing and such claims are accepted at face value, at least at time of hire.  This literally true.

Sadly, I have seen peer counselors (and therapists and psychiatrists for that matter) with untreated axis II disorders do great harm.

3. The sudden, poorly thought-out growth in peer services is driven by feel-good politics.

This true statement does not discount the possibility of benefit from having peers working in the system, but, it does tell us something about the process that led to the current situation and can illuminate how preventable problems were allowed to fester.  The peer counselor initiative may have a grassroots origin in the consumer/survivor movement, but it came to fruition because of state legislatures and state level department heads made the decision that peer delivered services is a good thing and made it so through law and regulation that, if not mandates, at least incentivises the practice in many states.

System changes driven at the state level are seldom well considered.

4.  And it is powered by cost cutting.

Medicaid reimbursement for services delivered by a peer counselor is considerably less than reimbursement for services provided by bachelors and masters level clinicians.  This impacts state budgets.

Need I say more?

Recovery or Denial?

“The Recovery Model.”  It sure sounds good, don’t it?  Recovery is one of the now buzzwords.  So, what does it really mean?  Did someone find a cure for schizophrenia?  Because, if they did, it’s a well kept secret.

The recovery model promotes the idea that people can recover from mental illness.  This is an important concept for a lot of reasons, not the least of which is that it promises to counter the phenomenon of people getting labeled and institutionalized and then forgotten.  It challenges the neglectful attitude that people can’t get better.  It highlights the fact that some problem behaviors are actually a result of institutionalization and over-medication.  It provides hope.  These are good things.

It is also used by state human services departments as a rationale for cutting or even eliminating funding for secure residential care for people with severe psychiatric disabilities.  The result?  People with severe disabilities are forcibly moved to community placements, and if-and-when they don’t make it, they end up on the streets.

That sure-as-shit don’t sound like recovery to me.

The fact is, there are some people who will get better with treatment (or sometimes even without) and there are some with more severe conditions who will not recover and need continuing treatment and care.

Yet again, we have a treatment model that is not based on science, but on political and economic expediency and because there is so much political correctness and complacency in the system, very few seem willing to speak up about it.

Dr. Munetz put it with nicer words than I can muster in his letter to Psychiatric Services (APA journal):  Denial of Mental Illness

Maybe, just maybe, this is the beginning of an honest discussion of the issues.  That would be real hope.

An Outline of Farce in the Public Mental Health System

As I see it . . .
This is just a partial list to get started with.  Not in any particular order.

• Blind Advocates—There is a tendency among mental health workers to advocate blindly regardless of actual clinical need. This is far more true in the mental health system than is found in the developmental disability services arena or the addiction treatment arena.
• Blind advocates will misrepresent the truth about their clients to potential landlords, employers and even other mental health professionals in order to get their client whatever he or she wants without consideration for the fact that by not addressing the underlying problems they are simply setting their client up for another failure.
• Some professionals will implicitly or explicitly promote fraud as they look the other way when their clients lie about income and symptoms in order to maintain entitlements.
• We’re All Disabled—creation and promotion of disability. Some mental health professionals seem to be of the opinion that any client who comes to them or their program should get cash disability payments. Some go so far as to misrepresent the severity of the clients' condition in order to help them get disability. Very little thought seems to be given to the fact that someone who is not truly disabled will ultimately be detrimentally affected by being told they are now disabled (and shouldn’t work) and by being escorted into the Social Security trap.
• You Need My Help—nurturing or creating dependence on the therapist and the system. It is truly overwhelming how much of public mental health resources (Medicaid and Medicare) are channeled into treatment models that have no positive clinical outcomes except the promotion of more mental health services.
• Cherry Picking—therapists and programs who are only willing to work with favored (i.e., easy-to-work-with) clients and unwillingness to work with clients with actual severe disabilities with difficult behaviors associated with their disability. Where does this leave people with severe disabilities? Overcrowded state institutions or the street. Where is the compassion?
• Pseudoscience—use of pseudoscientic data to bolster vacuous treatment models. Just take a few examples, out of many:
• Eye Movement Desensitization and Reprocessing—belief that having a client track a moving finger or object with their gaze while concentrating on a stress inducing thought will reduce symptoms of mental illness.
• Neurolinguistic Programming—assumes that by tracking another's eye movements and language, an NLP trainer can shape the person's thoughts, feelings, and opinions (There is no hard evidence to back this up).
• Emotional Freedom Technique—tapping acupuncture points with your fingertips. The principle behind EFT is that negative emotions can cause disturbances in the body's “energy field.” Your tax dollars hard at work, tap, tap, tap . . .
• Diagnostic Fads—faddish use of popular diagnostic categories and treatment models. The result is overwhelming increases in certain diagnoses due to popularity rather than objective facts. There are a number of reasons behind diagnostic fashion crazes but the primary driving force seems to be a widespread culture of pathologization of day-to-day problems. People are increasingly demanding that personal and interpersonal problems be described through a disease model and treated with medications or other quick fixes. Added to this is the commercial pressure from the army of therapists out there looking for business and, of course, the massive influence of the pharmaceutical industry. Some examples of diagnostic fads:
• ADHD—this seemed to peak in the Nineties and was driven by schools, parents and society at large moving away from traditional methods of child discipline and seeking new forms of behavioral control for the modern child (Ritalin^Ò). In its heyday, in the late Nineties, some elementary schools had upwards of 25% of young boys diagnosed and on these medications. Its popularity has diminished, only a little, because of the rampant problem of boys and girls on amphetamine-based medications growing up (all too quickly) into methamphetamine addicts.
• Bipolar Disorder—this is a very real and serious disease. However, sadly, it is very poorly defined. Many professionals are confused by the diagnosis and do not really understand it. It has become a very convenient label to throw at anyone with mood and behavioral difficulties (gee, isn’t that the entire human race?). This diagnosis became very widespread in the Nineties and was, and still is, very popular among adults who just want something to deal with emotions that get in the way of professional and relationship successes. It got another boost in the 20-Ought decade when anti-depressant drugs were found to increase the likelihood of teen suicide. The solution? Yeah, we'll just slap a Bipolar label on ‘em and feed ‘em Lithium Carbonate for breakfast. Problem solved.
• Dissociative Identity Disorder (AKA Multiple Personalities)—Where do you even begin with this one? So for one thing, it’s very very questionable whether this is even a real disease. But, the point I wanted to make here is that this diagnosis has mushroomed quite recently. You might remember the big implanted/recovered memory scandal of a few years ago? Yeah, well all those mentally unbalanced therapists who were driving that bus are still out there and still practicing. Now they don’t do the recovered memory thing anymore because they don’t want to get sued, but they are pushing this diagnosis hard. It is a sick, sick thing when a therapist plants and nurtures a mental illness in a client for their own emotional and financial gain.
• Posttraumatic Stress Disorder—yes, this is real, but it is way overdiagnosed. Humans are, in fact, quite resilient. I am here to tell you that not everybody who has experienced trauma needs to take drugs or spend money on a therapist. PTSD is on the crest of a wave right now. There are some therapists out there who have reduced their professional vocabularies down to a single word: Trauma. Yes, understanding trauma is very important for promoting mental health, but in the hands of confused but well meaning professionals, it leads to drowning in past traumas with absolutely no clue about how to help a person recover and build resilience.
• Autism Spectrum—another very real and very serious disease that has become exceedingly popular and chic among parents and even among adults who have only very minimal signs of the disorder.  Here is another case of individuals with severe disabilities losing resources to people who don't really have a disability
• The Paradigm Pendulum—quick radical changes in paradigms based, not on science, but on politics, popular culture, political correctness, and economic incentives/pressures. This problem has plagued psychology/psychiatry from the very beginning. The human brain is maybe the most internally complex organ known to biology and empirical science (not psychology) is only now beginning to scratch the surface of this amazing complexity. So what has driven psychology/psychiatry over the past century? I don’t know what you call it, but isn't empirical science. So, lacking a true empirical basis, what drives these paradigm shifts? Ideology and wishful thinking, I say. That’s why the history of paradigms in psychology looks a lot more like the history of politics than it does medicine. There are thousands of theoretical models out there, most of whom bit the dust long ago, but there is a bigger pattern in which the culture seems to go back and forth between the two great paradigms of the biomedical model and the psychosocial model. In recent history, the biomedical paradigm gained overwhelming ascendancy in the Eighties and into the Nineties on the Prozac locomotive and the “chemical imbalance” explanation-for-everything. Now that’s out, the new slogan is “trauma,” and the psychosocial paradigm is king. But, the cracks in the façade are already developing and there is a building swell of genetics research that’s threatening the party-line. Look at your watch, give it 10-15 years and the medical model will be back on top again. You can put money on it.
• I’m Not Mentally Ill But You Have to Support Me and Serve Me—psychiatric consumers and survivors who represent their own personal interests but packaged as social activism. How many times can someone unironically claim there is no such thing as mental illness, yet on the other side of their mouth, demand more and more services from the mental health system? It is a fact that very few people who publicly represent themselves as consumer/survivor activists have ongoing severe mental illness. As a consequence, the interests and needs of people with severe disabilities continue to go unheeded. Decades after “deinstitutionalization” we still have people with severe mental illness housed in deplorable conditions in institutions, prisons, emergency shelters, and the streets. Are these people represented by the self-styled activists? Not that I see. But, the full-time activists are marshalling all their energies to address their personal pet peeves while many of them fraudulently continue to draw down social security payments. Listen, Buddy, if your doing networking and activism 60 hours per week, you are perfectly capable of getting a job just like anyone else and you have no right to take public disability payments intended for people who can’t work.
• Drug Money—psychiatric medications are big business, in fact, prescription drugs have the biggest profit margin of any major industry, even bigger than the petroleum industry. Where do they spend their money? Just like any for-profit industry, a sizeable portion of expendable resources goes into promoting their products. This certainly includes advertising. It also includes funding biased research that promotes their products; flooding journals and literature with redundant studies that promote their products; deceptive “public education” campaigns; creating and financing activist and consumer groups that promote their products; etc. You get the idea. It has a huge huge impact on beliefs and practices in the mental health field. When encountering McScience^Ò, buyer beware.
• Let’s Play Pretend—politically correct professionals who willfully misdiagnose or simply avoid properly identifying personality disorders or any problem that fails the political correctness test. Borderline Personality Disorder, as one example, is often diagnosed, incorrectly, as depression, bipolar, PTSD, and dissociative disorders. This is pervasive and causes no end to problems in mental health programs where the actual issues are misunderstood or ignored. Conflicts occur between professionals resulting from attempts to address and discuss the problems while not being free to identify the problems properly. Resources are taken away from disabled individuals in order to support massive amounts of services to individuals who are not significantly disabled and may not even have a severe mental illness.