TED Talk Outline

Thesis:

  • I am looking at the paradigm shift of how Americans and the U.S. have thought about and treated our mentally ill population.

 

What is mental illness and how has the definition we use today changed from that of 50 years ago?

  • As defined by today’s mental health experts, mental illness refers to a wide range of mental health conditions — disorders that affect your mood, thinking and behavior. Examples of mental illness include depression, anxiety disorders, schizophrenia, eating disorders and addictive behaviors (Mayo Clinic).
  • Several issues surrounding mental illness diagnoses:
    • Tricky to differentiate between normal mental health and a mental disorder
    • Doctors typically look for a few key signifiers to help them
    • The first aspect they look at is a person’s behavior. Something like obsessive hand washing or drinking too much alcohol could be a symptom of a mental health condition
    • Next they discuss a person’s feelings; signs of deep sadness or ongoing anger can signify a problem
    • Finally, mental health experts review a person’s thoughts and their thinking. A person with a mental health condition sometimes has fixed beliefs or thoughts of suicide that are tell tale signs (Mayo Clinic).

 

History of mental illness:

  • In the 1880s, reporter Nelly Bly while on assignment for a newspaper, agreed to be institutionalized in a mental facility to see firsthand how the inmates were treated. Her article was a huge success and was the first real piece of literature that described the horrors of these mental institutions. Before she was brave enough to experience the torture first hand, people were happy with throwing anyone who showed signs of mental illness in these terrible facilities in order to give the general public a sense of security. The approach to locking mentally ill people away in order to ignore the problem was going to be addressed in the coming decades.
  • In the 1930s, Sigmund Freud pioneered extensive research efforts to figure out what was causing the “madness” within the mentally ill. Unfortunately, the public was not willing to wait the years it would have taken to test all of Freud’s theories and health experts began taking radical steps to cure mental illness. The most well known forms of “medicine” doctor’s used in the early 1900s was electric shock therapy and lobotomies.
  • The deinstitutionalization movement began in the 1950s with a huge effort to get people out of mental health facilities and move them into living communities that would better fit their needs. Unfortunately, these new communities were overwhelmed with the huge influx of patients and were unable to provide shelter to everyone. Because of this, many people dropped out of the system and had no other choice other than to live on their streets. One study that was conducted in 1988 found that 28% of the homeless populations in the United States were mentally ill (Dual Diagnosis).

 

Analysis of shift:

  • One example of how we have changed our thinking about mental illness can be seen by looking at posttraumatic stress disorder (PTSD) and how it responds to cognitive-behavioral therapy (CBT). Early data suggest that CBT following a traumatic event can reduce the incidence of PTSD in those at greatest risk. Similarly, data from several studies support the efficacy of lithium for reducing the number of suicides in those with mood disorders. In a meta-analysis of 32 trials, persons treated with lithium showed a 74% reduced risk of death from suicide (Insel).
  • The growing realization of how much mental illness affects health care costs and the number of lost work days is changing the trend of treating the mentally ill as less sick than those people with physical illnesses (Doebbeling).
  • We have also figured out recently that many mental health disorders appear to have a biologic component, much like disorders that are considered neurologic, such as Alzheimer disease (Doebbeling).
  • Now, the public is more easily able to distinguish long-lasting (chronic) serious mental illness that severely limits a person’s daily activities or ability to work (such as an ongoing, lifelong psychosis) from brief but serious episodes of symptoms that are expected to resolve and from chronic symptoms that do not interfere with activities or work (Doebbeling).
  • With the movement of deinstitutionalization, greater emphasis has been placed on viewing mentally ill people as members of families and communities. A decision by the U.S. Supreme Court in 1999 significantly aided this change. This decision, called the Olmstead decision, requires states to provide mental health treatment in community settings whenever such placement is medically appropriate (Doebbeling).
  • Research has shown that certain interactions between a person with mental illness and family members can improve or worsen mental illness. Therefore, family therapy techniques that prevent the chronically mentally ill from needing to be reinstitutionalized have been developed. Today, the family of a mentally ill person is more involved than ever as an ally in treatment (Doebbeling).
  • A newer technique called assertive community treatment (ACT) has been developed in order to provide a safety net for people with chronic serious mental illness. ACT uses a team of social workers, rehabilitation specialists, counselors, nurses, and psychiatrists (a multidisciplinary team). The team provides individualized services to people who have a serious mental illness and who cannot or will not go to a doctor’s office or to a clinic for help (Doebbeling).

 

How we view the shift & where it’s headed:

  • I think that most people would agree that any positive progress in the mental health industry is a good thing. An issue that is emerging from easily accessible information about mental health is that everyone feels like an expert in diagnosing mental illnesses and the severity of the situation isn’t fully comprehended. With anyone being able to WebMD some symptoms and get a mental health diagnosis, there are people who do not understand that these conditions are real and negatively effect millions of Americans everyday.

 

Significant moments of shift:

  • July 3, 1946: President Harry Truman signs the National Mental Health Act, calling for a National Institute of Mental Health to conduct research into mind, brain, and behavior and thereby reduce mental illness. As a result of this law, NIMH will be formally established on April 15, 1949 (PBS).
  • 1955: In the United States, the number of hospitalized mentally ill patients peaks at 560,000 (PBS).
  • In the early 1960s, states embarked on an initiative to reduce and close their publicly operated mental health hospitals, a process that became known as deinstitutionalization. Advocates of deinstitutionalization envisaged that it would result in the mentally ill living more independently with treatment provided by community mental health programs.  The federal government, however, did not provide sufficient ongoing funding for community programs to meet the growing demand.  Concomitantly, states reduced their budgets for mental hospitals, but provided no proportionate ongoing increases in funding for community-based mental health programs. As a result, hundreds of thousands of mentally ill persons were released into communities that lacked the resources necessary for their treatment. The system was, and is, broken, an assessment underscored in a 1999 report from the Surgeon General’s Office, titled Mental Health: A Report of the Surgeon General, indicating that, “Even more than other areas of health and medicine, the mental health field is plagued by disparities in the availability of and access to its services.” Consequently, many of the individuals released into the community without support ended up incarcerated;  it is fair to say that instead of being “deinstitutionalized” a great number of individuals suffering with mental illness were, in fact, “trans-institutionalized” into America’s jails and prisons (Health Affairs).
  • 1963: In the U.S., passage of the Mental Retardation Facilities and Community Mental Health Centers Construction Act provides the first federal money for developing a network of community-based mental health services (PBS).
  • 1979: A support and advocacy organization, the National Alliance for the Mentally Ill, is founded to provide support, education, advocacy, and research services for people with serious psychiatric illnesses (PBS).
  • 1980: Number of institutionalized patients drops to 130,000. This is possible because newly discovered anti-psychotic drugs allows people to live in communities without constant supervision (PBS).

 

Ramifications of shift:

  • Blaming mass shootings and violence on the mentally ill could lead our nation to lose all of the progress we have made in the past 100 years.
  • We could be headed towards another shift in the way we diagnose mental illness. Currently, we diagnose mental illness by late-stage symptoms. If the way we medically address mental illness now continues on the same path, we may be able to better treat those affected by illnesses with a more preemptive approach.

 

Violence and Mental Illness:

  • Due to the readily available and better research surrounding mental illness, the general public could have a sense that they know all about the mentally ill and can therefore make policy suggestions about mental illness. Unfortunately, a lot of important facts and figures fall through the cracks and people are not getting the full picture regarding mental illness.
  • Many people experience mental illnesses, so having had a diagnosed illness is not a very specific predictor of violent behavior. This means that many proposed policy approaches, from expanded screening to more institutionalization, are unlikely to be effective. Expanded access to effective treatments, although desirable, will have only modest impacts on violence rates. Most people with mental health problems do not commit violent acts, and most violent acts are not committed by people with diagnosed mental disorders (Freedman).
  • The dilemma with respect to our expertise in assessing the risk for violence in these patients is quite analogous to the evaluation of suicidal risk. Unless a patient specifically acknowledges an intent and plan, we can only determine the extent to which that individual is within a group at greater risk for violence than the general population. Factors that determine the time and place of a violent act, such as a later chance stressor or provocation, may not be known either to doctor or patient at the time of an interview. Violent behaviors are often well planned over a long time but then executed impulsively in a brief period of high emotional arousal. Potentially violent individuals may not provide information regarding their plans or schemas because they are exceptionally guarded. Warning signals may be more frequently observed in public settings than in the psychiatrist’s office, where lower levels of stimulation allow patients to remain more circumspect (Freedman).
  • Ethical concerns about inappropriately stigmatizing mentally ill patients as potentially violent and then mandating treatment reflect current limitations in the accuracy of our assessment and the effectiveness of our treatment (Freedman).
  • Advocates for people with mental illness respond by pointing out the often weak association between mental illness and violence, and pleading that isolated violent acts not lead to further stigmatization and loss of civil liberties for those with mental health problems. Some commentators call for widespread screening to identify those in need of mental health treatment. Others take a different tack, urging a return to an era when people exhibiting disturbed and disturbing behavior were more frequently institutionalized (Glied).
  • Epidemiological research suggests that nearly half the population-whether or not involved in crime-experience some symptoms of mental illness over the course of their lifetimes. A recent population estimate has found that 46% of US adults meet criteria for a major mental illness. Meanwhile, only 33% of the US population report seeking professional care for a mental health problem in their lifetime. The very high lifetime prevalence of illness and treatment seeking helps explain why virtually every story of a violent act can be linked to some clues of psychological abnormality or mental health treatment (Glied).

 

How do mandatory sentencing laws effect the mentally ill, specifically regarding drug usage and abuse?

  • During the 1990s the prison population grew at seven times the rate of the U.S. population and is expected to continue to increase well into the new millennium (Wees, 1996).
  • Transinstitutionalization, the entry of mentally ill individuals into the criminal justice system, has also changed the face of prisons (Bonovitz & Bonovitz, 1981; Snow & Briar, 1990; Steadman, Monahan, Duffee, Hart- stone, & Robbins, 1984; Teplin, 1990). Although Steadman and associates (1984) concluded that deinstitutionalization did not lead directly to the increased numbers of mentally ill found in prisons during the decade he studied (1968 through 1978), he did not dispute that the numbers of men- tally ill in prisons were increasing at rates greater than one would expect.
  • It’s estimated that 20% of America’s prison population suffers from a serious mental illness. According to the American Psychiatric Association, on any given day, between 2.3% – 3.9% of inmates in state prisons are estimated to have schizophrenia or other psychotic disorder; between 13.1% -18.6% have major depression; and between 2.1% – 4.3% suffer from bipolar disorder. Across the nation, individuals with severe mental illness are three times more likely to be in a jail or prison than in a mental health facility and 40% of individuals with a severe mental illness will have spent some time in their lives in either jail, prison, or community corrections (Aufderheide).

 

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