Feb 26, 2013

Dealing with the tyranny of one-size-fits-all systems

Sequential Intercept Model
We’re human. Nothing we do is perfect. That goes double for our formal systems, including the mental health system.

Whatever we do, however much time we spend at the drawing board, no matter how many people participate in our focus group or get engaged in the public debate, no matter what the strength of our computer models, we just can’t ever get it perfect. At least not perfect for everyone.

There is always someone for whom the Best System is not optimal. It makes them walk an extra mile, interferes with their dinner plans, forces them to move to a new town, costs them their job, lowers their property values, violates their principles, or is against their religion.

Because systems are never perfect, they are doomed to generate conflict and dissent. Trouble is inescapable, no matter how benign or well-intentioned the system tries to be. Systems have their limits and their rules and when the system reaches its limit something has to give. When people push at the limits of a system they may occasionally gain a benefit that appears to violate system rules, but more likely they will end up being coerced or hurt. The mere existence of a system impacts populations in ways the people in it can’t entirely control and often cannot even see.

Some systems are explicitly designed. Others are self-generated, developing from custom and an accumulation of habits and small decisions. Whatever the origin, every system encounters stress over time as it encounters unforeseen circumstances or reacts to conflict. The durability of the system’s formal structures, resources and operating rules defines the system’s resilience, its capacity to respond and adapt. The system holds together, or things change, sometimes radically. We might call this process of adaptation System Darwinism.

System Darwinism still does not guarantee an optimal outcome for everyone. There will always be someone for whom the system does not work.

This realization, that systems will always be imperfect, creates opportunities for innovation.

We can make decisions about priorities, starting with What Really Matters: What is the value in our hearts, the success of the system or the health of the people? All of the people? Most of the people? People like us? What is our responsibility toward the people that the system serves imperfectly?

If we care about a particular person, and the person can't get help from the system, we look outside the system for the help the person needs. That's common sense. But what if the system is mandatory? What if it's the legal system that's not working for the person?

We know how to create mechanisms for that. It's called diversion. In the legal system, cases might get sent to mediation or arbitration instead of to a jury. If that takes care of the dispute, the formal case gets dismissed. We might even create diversion systems that run parallel with the formal system. When mental health connects with criminal justice, system planners use a technique called the Sequential Intercept Model to align an array of diversion opportunities to the stages of criminal case processing. The most effective diversion keeps people from having any contact with law enforcement at all. As people move through the criminal justice process, they suffer increasingly severe consequences. An arrest record. A conviction. Potential loss of liberty or earnings. Still, diversion at any of the stages might save a person from the next full dose of consequence.

Is there room for diversion in the mental health system? Of course there is. Mental health is mostly not a mandatory system. It fills quite a bit of our civic and economic space, but participation is mostly voluntary. Only in the toughest situations is anyone really forced to participate.

We know that American mental health is not a well-designed system. Its origins lie in reactions to primitive stigma and fear. It is built from the accretions of 19th Century thinking and a committee-driven diagnostic catalog that everyone seems willing to argue about. We know the economics of the system do not work. The system is always starved of resources. Only experts seem to know what’s good for people. We know that the pills the system offers are hard to take, and work sometimes, for some people, but tend to create their own problems. We know that the mechanics of the mental health system are often coercive. The system organizes services around a mental model of permanent sickness.

How attractive is that? Would you opt to participate a system like that?

If you were a person who suffered trauma and victimization in your life, would you be likely to benefit from a system driven by labeling and coercion?

This is the same sort of issue many people who seek to attain sobriety face when confronted with the values and traditions of AA. If you have been victimized, are you motivated by the prospect of labeling yourself powerless once again? If you are not religious, are you likely to cherish opportunities to appeal to a Higher Power?

So here’s my proposal. Let’s invest in some recovery techniques that work for people who do not want to deal with the standard medical-model system. Here are some workable suggestions. Put some resources into them, focused on outcomes, not techniques. Let people choose what is compatible for them.

Or even better, let’s apply a systematic diversion model to mental health. Try the cheap benign non-medical methods first. We can put mentoring, emotional support, suicide prevention and self-help everywhere. Let people cool down and regain their composure in some safe location. Let folks work through their distress without being smacked with a diagnosis. Use the non-medical system as a buffer for the medical system. Put it in emergency rooms, after school programs, neighborhood clinics, employee assistance programs, union halls, Grange halls, 4-H Clubs, YMCAs, and church basements. And wherever guns are sold.

We should realize that our reorganized system won’t be perfect either. But it could make things better, for many more people, at lower cost, with fewer side effects, and much less conflict. It could get more people involved in caring for each other, and foster a sense of normalcy instead of sickness.

It might even wipe out stigma.

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