Dec 27, 2013

Can NAMI survive E. Fuller Torrey’s culture war?

The new boss at NAMI hasn’t arrived yet, but E. Fuller Torrey has a list of her known associates and is already on the attack. Pete Earley sees this as part of a culture war within NAMI (a mental health group I have generally supported, and have occasionally worked for, since the 1990s). Earley writes
Torrey has become the de facto leader of the so-called “NAMI CLASSICS” who believe NAMI should focus on serious mental illnesses, such as schizophrenia, bipolar disorder and depression. This group is largely pro-medication and pro Assisted Outpatient Treatment laws, which require individuals who have multi-hospitalizations and/or violent pasts to be forcibly treated. In recent years, more and more consumers  (persons with mental illnesses) have joined NAMI and they often oppose “paternalism” in favor of self-determination.
Although Torrey helped build NAMI into the most influential mental health organization in the nation, he angered many when he created his own non-profit, the Treatment Advocacy Center, to push for passage of AOT laws as well as other changes. A favorite speaker at past NAMI national conventions, Torrey has not been invited to speak in recent years and the last time his name was raised, some board members threatened to boycott the convention if he appeared. This year, NAMI invited journalist Robert Whitaker, known for his books that question the use of anti-psychotics,  a move that would have been unheard only a few years ago.
NAMI has been undergoing a culture change for quite a while. One factor behind this is the mere passage of time. After some 35 years of organizational existence, NAMI has outlived many of its founders. Plus, nowadays, most Americans with mental illness have never been hospitalized, and have only lived in a deinstitutionalized world.

In addition, issues relating to mental illness are so raw, so difficult, so complicated, it’s almost an injustice to say there are two factions within NAMI. I think it is more useful to say that there are a million issues within NAMI, and each of these issues has at least two sides. Mental illness is a big slice of the universe. It has its own politics, its own economy, its own connection with justice, and thousands of years of violence, trauma, shame, and shunning-driven history to give it a bitter sort of flavor.

My position on Torrey and his group is pretty straightforward. I think Torrey is right when he says we need a mental health system that addresses society’s toughest situations. Torrey’s group, the Treatment Advocacy Center, helped some of my friends try to reestablish contact with their son, who was living in horrific circumstances. On the other hand, I really dislike Torrey’s politics. He is an old-fashioned authoritarian who has been attacking the most benign and progressive aspects of US mental health policy for at least two decades. He has gained traction on the right-wing publicity circuit since Newtown, mostly because he offers the gun lobby a diversionary tactic, and is not completely off-base. Torrey’s work is behind the worst parts of Tim Murphy’s proposed mental health reform legislation (the parts that muzzle advocacy groups and gut funding for nonclinical recovery organizations).

I believe NAMI can avoid a culture war by making the most of its new-found and hard-won diversity. NAMI can advocate for smart, nuanced approaches to complex issues.

For example, what Torrey gets most wrong is his focus on the “most serious” cases. This sounds sensible at first, like triage on the battlefield, but in the long run does not work. Less serious cases need resources too, and fast. They cause the largest impact on the economy, and disrupt many more people’s lives. Unresolved mild cases eventually become severe cases. A better policy position is to say that everyone who needs medical care should have prompt access to the right kind of treatment.

Torrey has been writing about the loss of hospital beds for the last year or so.  He pines for the bygone days of big asylums. Some people do need a long-term residential solution for safety reasons, but they are such a tiny minority of the population. Do we need huge hospitals? No. Bigger facilities do not create better clinical outcomes. On the other hand, we do need enough capacity throughout the healthcare system so everyone can have access to the intensity of service and the structure that they need.

Assisted Outpatient Treatment (the kindest possible term for Treatment By Force) is no panacea either. The practicalities of modern life make institutional confinement impossible for many people who are not safe without treatment, and people deserve choices regarding type and dosage of medicine. This is violent coercive state action, about as welcome as a shock collar or a house arrest ankle monitor. Torrey never admits that involuntary treatment can be as traumatizing as a rape.

NAMI would do well to resurrect the Alliance part of its organizational heritage. The essence of alliance is collaboration, not control. Collaboration is possible even when there is such complexity and so much suffering on every side. We want solutions for everyone, a way for everyone to succeed, a way for everyone to reach their fullest capacity, and to contribute their gifts and talents as they make progress.

I think the future of mental health involves more complexity, not less. Nonclinical solutions, more peer support, more disclosure, less stigma, some honest talk about safety, better clinical process, more family involvement, better housing. We need whole-system solutions. Everyone needs a chance to pitch in.

Dec 24, 2013

Redesigning Recovery

Every time I revise my book Defying Mental Illness  (it's an annual, like What Color Is Your Parachute) , my view of mental health recovery becomes more positive.

If you think about recovery in terms of human development and social roles, then recovery is about getting back on track with life. This may take time, and medical care, and the support of friends and family, but most people get there.

The 2014 edition of Defying Mental Illness is available in print here and is working its way towards Amazon and other book distribution, but the ebook reader versions (as well as online views and PDFs) are available now. Download the free sample, or read it online, and you’ll see what I mean.

Please let me know what you think.