Written Testimony by Loren R. Mosher, M.D.,
for the Joint Committee on Mental Health Reform (JCMHR) -
Credentials:
I am born and raised in
California, a board-certified psychiatrist who received an M.D., with honors,
from Harvard Medical School in 1961, where I also subsequently took psychiatric
training. I was Clinical Director of
Mental Health Services for San Diego County from 7/96 to 11/98and remain a
Clinical Professor of Psychiatry at the School of Medicine, University of California
at San Diego. From 1988-96 I was Chief Medical Director of Montgomery County
Maryland’s Department of Addiction, Victim and Mental Health Services and a
Clinical Professor of Psychiatry at the
From 1968-80 I
was the first Chief of the NIMH’s Center for Studies of Schizophrenia. While with the NIMH I founded and served as
first Editor-in-Chief of the Schizophrenia Bulletin.
From 1970 to 1992 I served as
collaborating investigator, then Research Director, of the
In 1980, while
based at the University of Verona Medical School, I conducted an in-depth study
of
In addition to
over 120 articles and reviews, I have edited books on the Psychotherapy of
Schizophrenia and on Milieu Treatment. Our book, Community Mental Health:
Principles and Practice, written with my Italian colleague, Dr. Lorenzo
Burti, was published by Norton in 1989.
A revised, updated, abridged paperback version, Community Mental
Health: A Practical Guide, appeared in 1994. It has been translated into five languages.
Most recently I founded a consulting
company, Soteria Associates, to provide individual, family and mental
health system consultation using the breadth of experience described above.
In many parts
of the country thinking about public mental health systems has moved away from
the biomedical model, initially to a psychosocial rehabilitation orientation,
and more recently to a recovery based model.
Each change represents a move toward a more holistic view, increased
self-management in treatment, greater emphasis on independent living and
community integration and protection of rights of system users. As a whole it means much less hierarchical
systems and greater equality of staff and users.
When
considering mental health reform it must
be recognized that mental health care is a system. Programs making up mental health systems
share the following characteristics: They are labor intensive, relationship
based and relatively low technology. The system’s elements should include:
Prompt, accessible, client centered, recovery oriented, quality mental health
and rehabilitation services; decent affordable
housing; and appropriate, ongoing self-help focused social supports. Because they address basic human needs
systems that contain an array of these services have been shown to be both cost
effective and voluntarily used. Such systems must be adequately funded but
reform must also include attitude change and reorganization into less
institutional, human sized programs.
Reform to produce co-ordinated
community based systems of care needs guidelines: (1) a shared set of values
and (2) common organizational (3) interpersonal and (4) clinical
principles. These four elements of a
systemic organizational framework can guide the committee’s reform
deliberations. Because they are non-specific, they are nearly universally
applicable.
1. PROGRAM VALUES
¨
Do no harm
¨
Treat, and expect to be treated, with dignity and respect.
¨
Be flexible and responsive
¨
In general the “user” (client, patient) knows best. We each know more about ourselves than anyone
else. This is usually a vast untapped
reservoir of valuable information.
¨
Choice, the right to refuse, informed consent, and
voluntarism are essential to program functioning. Without options, freedom of choice is
illusory. Involuntary treatment should be difficult to implement and used
only in the direst of circumstances.
¨
Expression of strong feelings and development of potential
are acceptable and expected – and are not usually signs of “illness”.
¨
Whenever possible, legitimate needs (e.g. housing, social,
financial etc.) should be filled. Without
adequate housing, mental health “treatment” is mostly a waste of time and money.
¨
Risks are part of the territory; if you don’t take chances
nothing ever happens.
¨
Reliable funding stream
¨
Catchmented responsibility – no “shift and shaft” allowed
¨
Responsible, multi-disciplinary, multi-function, mobile
teams
¨
Decentralized authority and responsibility to allow on the
spot decision making
¨
Use of existing community resources
¨
Multi-purpose mental health/social services centers.
¨
Non-institutionalization:
Residential care (i.e., hospitals and IMD’s) is expensive and often
creates or reinforces problems. They
are, by definition, abnormal environments and should be used sparingly.
¨
Multi-dimensional outcomes must be monitored and fed back
rapidly.
¨
Citizen/”user” participation is vital for program planning
and oversight.
(All help facilitate the development of relationships)
¨
Positive Expectations
¨
Atheoretical need to understand – try to find an explanation
for what is going on
¨
Continuity of relationships across contexts
¨
“Being with”., “standing by attentively” – getting oneself
into the other’s shoes to better understand “the problem”
¨
Concrete problem focus ( problems, in contrast to diagnoses,
generate questions and possible solutions)
¨
Relational “partnership”, doing together (preserves “user”
power)
¨
Expectation of self-help (“users” need not be so in
perpetuity)
¨ Contextualization– we all have histories that can only
be understood by considering the contexts within which they developed.
¨
Preservation and enhancement of “user” personal power and
control. Mental health professionals do
not necessarily know what is best for their clients/patients – their role
should be to keep them continually involved as the treatment process unfolds.
¨
Normalization (Usualization): Culturally sensitive societal
norms should be applied when treatment plans are developed. The most “normal”, least restrictive,
alternative should always be tried first.
If you treat people as normal they tend to behave normally.
We have a more than adequate
knowledge base to implement reform. More
studies and dust gathering reports are not needed. What is needed is the political will,
community involvement and financial resources necessary to make change happen.
It is my belief that this bill will
impede the development of the responsive co-ordinated service systems outlined
above because it will encourage the use of the most expensive resource
(hospitals) to the detriment of voluntary community based services of known
cost-effectiveness. Furthermore, it will
give power to a large number of persons to deprive citizens of their civil
rights on the basis of “the need for treatment”, an extraordinarily broad, and
basically limitless, category. Involuntary treatment is already overused in
Soteria Associates:
Loren R. Mosher M.D., Director
858-550-0312, fax
858-558-0854
Email-102754.3341@compuserve.com