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Recovery Model Shows Promise in Helping Mentally Ill

Some programs show great promise — but they haven't been propagated.
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Part III of a four-part series looking at the sorry state of treating the mentally ill — beyond warehousing people in institutions or prisons — and the tentative efforts to improve the situation. Part I looked at the scope of the problem and the downbeat assessments by experts; Part II examined how the severely mentally ill end up in prison instead of receiving help.

Patrick Kaufmann hit bottom, but it took a long time. Reeling from depression and struggling with schizophrenic delusions, all he wanted to do was take drugs and be left alone. Fortunately, his family and an innovative program in Michigan based on a recovery-based model of mental health service called Assertive Community Treatment (ACT) didn’t give up on him.

Kaufmann had been in treatment for schizophrenia for a number of years, but it wasn’t until he was living with four people in a filthy apartment, scrounging for cigarette butts and eating mustard for dinner, that he decided things had to change. Still, it was a long road to understanding that he needed help.

At age 12 he first started experiencing depression. As it worsened through high school, he became despondent and tried to kill himself. He began to take a lot of illegal drugs, “which probably exaggerated the depression,” he said.

After high school, he took a summer job and then went to a community college in Pennsylvania, but by his second year he was severely delusional. He heard voices and believed he could change events that happened in high school simply by thinking about them. The college put him on academic probation, and he lost his apartment.

He was acting out violently and ultimately ended up moving home. There, he believed his parents were trying to control him. He got arrested and ended up in jail. His dog attacked his dad and had to be destroyed. He went from jail to a mental hospital where, at the age of 20, he was diagnosed with schizophrenia.

“From the hospital I went into an ACT program,” InterAct of Michigan in his hometown of Kalamazoo, Kaufmann said.

InterAct of Michigan, like other ACT programs in the country, provides a supportive team of people to work with seriously mentally ill individuals in a community setting, providing whatever each person needs to stay safe and manage his or her illness on a 24-hours-a-day, seven-days-a-week basis.

The team of professionals is likely to include a psychiatrist, a nurse, a psychologist, a social worker, a mental health caseworker, a substance abuse counselor, perhaps a probation officer and often a “peer support specialist,” an advocate who also has experienced mental illness. The team meets every day and provides what individual circumstances dictate.

So, for example, one client may need help with banking that day; another may experience a psychotic episode and require medical intervention; and yet another may need help finding adequate housing. The team deals with whatever presents itself, and the clients have a major say in deciding what happens. InterAct of Michigan has two ACT teams that serve 260 clients around the clock.

But Kaufmann, whose drug problems meant he had a “dual diagnosis” of mental illness and drug abuse, resisted treatment and left ACT.

Six years later, “I was doing drugs to the point that it was all day, every day. I just finally realized I had absolutely nothing,” Kaufmann said. “One night I lay awake all night, then called my ACT program in the morning and said I wanted to get back in.”

That was four years ago. Today, Kaufmann is employed at InterAct as a peer counselor and has started a nonprofit group — Power Branch — to support and serve others with mental illness who want to manage their own lives better. He got married a year ago, and he and his wife, who has bipolar disorder, just had their first child.

Some Ideas Are Working
Kalamazoo’s ACT program is one of hundreds around the country helping the mentally ill live successfully on their own, hold jobs and contribute to their communities. Michigan has more than 100 ACT teams alone, and such teams are in place in 34 other states. The model saves money and substantially reduces the number of days clients spend in hospitals compared with other outpatient treatment models. A variation called Assisted Outpatient Treatment, in which clients are compelled by the courts to enter the program, reduces incarceration and recidivism rates as well.

Another successful treatment model is Clubhouse, where clients find support and services in a community-based drop-in center. Typically, clubhouses offer counseling for their “members” that allows them to plan and manage their own recovery. They learn coping and social skills and are directed to mental health and employment services. They can also attend a variety of classes, like computer skills training and exercise. Like ACT, Clubhouse programs have been shown to be far less expensive than typical institutional or clinic-based treatment programs.

But getting counties and states to shift resources from entrenched programs to more innovative mental health models has been difficult at best.

“The recovery model is clearly the most progressive and encouraging model in treatment nationwide,” said Paul Erickson, medical director of mental health services at Cottage Health System in Santa Barbara, Calif. “It ties treatment to all aspects of the person’s life — work, relationships, housing, family community contributions. It’s moving from treating the symptoms to treatment of the person as a whole.”

The problem is, Erickson said, the resources to provide such services are severely limited. He oversees a 20-bed inpatient medical wing for both mentally ill and substance abuse patients in a hospital that serves a community of 225,000 people.

The county psychiatric care facility has another 16 beds. But according to the Treatment Advocacy Center, a national nonprofit group, a community of Santa Barbara’s size should have a minimum of 200 beds. And that’s just for crisis intervention. Community programs to serve the mentally ill beyond that are woefully underfunded as well, he said.

“The mentally ill need support in housing, getting to work, managing daily life. But this takes resources, and the resources that are available are sort of bare-bones to begin with,” Erickson said.

Erickson, who came to Santa Barbara from Harvard’s Cambridge Hospital in Boston, says he has to beg every day for county-funded services for the mental health clients who come into the hospital. Innovative programs like ACT, Clubhouse and Crisis Intervention Teams for law enforcement have all proved successful, but they are only sporadically implemented, he said.

“The knowledge base, capacity and medical care is all there to improve it. It’s the lack of political will and funding that’s been the problem,” Erickson explained.

“We’re sort of struggling here in California to move from the old model,” said George Kaufmann, Peter’s dad. The senior Kaufmann moved to California from Michigan nine years ago and is now a member of the state Mental Health Association board as well as an advocate with NAMI.

Even though Peter is stabilized, Kaufmann said he stays involved because the services that were available to Peter are not available in so many other places.

California, in particular, doesn’t have the array of services other states offer, he said.

“Many professionals look on the people as the problem — the disease is not the person,” Kaufmann said. “Mentally ill people want what everyone else wants: to have engagement in work and volunteer efforts, to have self-respect. They have to believe that they have something to offer. That’s a huge part of recovery.

“The best clinical outcomes for people with serious mental illness occur when they receive treatment and services according to a recovery model.”

Massachusetts has a pretty good program, Kaufmann said. And Michigan, despite its terrible economy, provides fairly effective recovery services by outsourcing all of its treatment programs, he added.

NAMI does a state-by-state report card every few years. The latest, from 2006, shows an overall national grade of D. The highest-rated states — Wisconsin, Connecticut, Maine, South Carolina and Ohio — all received B’s. Twenty-seven states received D’s or F’s.

Show Us the Money
One recent hopeful development in California (rated C on the NAMI scale) was passage in 2004 of the Mental Health Services Act, an initiative that imposed a 1 percent tax on those with incomes of more than $1 million per year. The proceeds from the tax will go to counties to provide new and improved programs for the mentally ill.

Funding has been slow in coming. The new tax generated more than $2.1 billion in additional revenues for mental health services in fiscal year 2006-2007 and was expected to bring in more than $1.6 billion in fiscal year 2007-2008 and $1.7 billion in fiscal year 2008-2009. But only $645 million had been distributed to local agencies through the end of fiscal year 2006-2007; an anticipated $1 billion was expected to be distributed in both fiscal year 2007-2008 and fiscal year 2008-2009, according to a California Department of Mental Health report to the state Legislature in May 2008.

Spearheaded by the state Mental Health Association board, it was an attempt to circumvent the current funding bureaucracy and bring in new dollars for needed programs. Technically, the money can only be used for new programs, a source of frustration for many in the mental health community. But Kaufmann said the dollars can be used for expansions of current programs, as long as they are based on a recovery model.

“It’s hopeful in the long run,” Kaufmann said.  “It’s just taking so damn long.”

Next: What will it take to gain a national score of A? One place to look: Australia.

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