Sep 18, 2013

Mental illness is broken

I think the whole experience around mental illness is broken, a total systemic failure.

Systems have life cycles. They start out along a spectrum from randomly generated (through tradition, for example) to thoroughly designed.  Whichever way they start, they follow wobbly patterns ranging from controlled to out-of-control, effective to ineffective, sustained to out-of-resources.

A problem-solving system such as education or criminal justice or healthcare starts out with formal elements (schools, courthouses, hospitals), plus basic  professional structures (doctors, lawyers, teachers) plus broad policies (constitutions, degree programs, practice guidelines) to guide future action.

In the operational stages, professionals and governing bodies develop traditions or protocols, and deliver services to the people who interact with the system. These decisions pile up. They affect how the system operates as a whole in the future.

An operational system that is supplied with sufficient resources delivers a satisfactory range of outcomes, aligned with the expectations of its governing authority, professionals and service users. But when systems fail, people suffer.

Signs of system failure include:

- High numbers of poor outcomes
- Collateral damage
- Correct decisions that create harmful social consequences
- Absurd outcomes
- Bad rhetoric
- Political correctness
- Not reaching people in time
- Waiting lists
- Case processing backlogs
- Restricted access to techniques that work
- Treatment protocols corrupted by service-rationing
- Turf issues focus on avoidance of responsibility
- Resorting to primitive methods, e.g. shunning, shaming, coercion
- a professionalized environment but professionals can't do what counts
- dehumanization of service users
- Frail (non-resilient) systems
- Financial incentives for delivering poor service arrays
- Poor geographic distribution
- Corrupt practices

Whether failing or functional, no system is perfect. Systems always fail some portion of the constituency they are meant to serve. Complex dynamic systems have multiple capacities, patterns of strengths, blind spots, weak spots, clumps of capacity, and specific trouble points. After a while, all of these are noticed, but only rarely are they seen as system failures. They are usually interpreted as aberrations no matter how frequently they show up.

Fixing failed systems

For any system, it is possible to map out problems, and add non-system resources to compensate. These non-system resources, generally speaking, involve either money or people. Unfortunately, unless the logic and infrastructure of the system are actually fixed, this strategy just adds more of what  is already not working.

The most comprehensive approach assumes that everyone inside and outside systems can help, and that every aspect of the system is worth questioning.

Every option is optimal for something. We can find out what people can do, what they like to do, and what they are are willing to do, and use these capacities in the discretionary space within the system and in places where the system does not operate.

We can also try to identify techniques which are professionally designed and validated, but that can be adapted and used by non-system personnel.

If the system is broken, the most urgent questions are "What is our most helpful, least toxic, least costly option?" and "What can we do that's just as effective but not as harmful as what the system offers today?"

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