Mental Health is Lost
Posted by Dr. Vollmer on February 20, 2015
What does being a mental health provider mean? Does it mean that we help people breathe, eat right and exercise? Does it mean that we tell primary care doctors which drug to prescribe, after a two question or nine question paper and pencil test? Does it mean that we point people towards groups, where the individual can share their story with other folks who after a fifteen minute assessment seem to struggle from the same issues? Do we help people by stating the obvious? If we do not understand psychic pain, if we think that a quick appraisal of the person’s mental state can tell the practitioner what to do next, then there are two main problems as a result. First, patients will not get better and they will need to seek help from other sources who may prey on the vulnerable. Second, practitioners will not learn the language of deep mental processes which sabotage and destroy otherwise healthy people and healthy relationships. As a result, if the delivery system ever changed back to an in-depth approach to mental health, there would be no practitioners skilled in drilling down to the root cause of mental suffering.
Yaddy, ya, ya….same ole….rant, but today I add a new issue. As mental health care delivery transitions away from mental health providers giving direct patient care, and serving more as a consultant to primary care, then we will see two problems. One is that the practitioner caught in the midst of this change is going to be very unhappy because that is not the work they signed up to do. It would be as if you told an internist that now all they could do would be to work in the Emergency Room. They would lose their opportunity for long-term relationships because their skill set is needed for triage. This might serve the needs of the population, but for the physician, this is a low blow. If they wanted to be an ER doctor, they would have chosen that in the first place, so the ground under the feet has been ripped. Second, those choosing to enter the mental health field are choosing a career of triage, and not long-term relationships, and as such, a different type of person will enter the field. Triage is a different skill set from long-term care, and hence the mental health provider will shift from a person who enjoys relationships with patients to a person who enjoys shift work. Again, the ER doctor has a different personality than the internist, and so this is true for the changing mental health delivery system.
Words like “integration” and “patient centered medical home” speak to a primary care physician who handles the ‘big picture’ meaning that mental health is being renamed “behavioral health” to suggest that changing behaviors can change mental pain, which although sometimes true, is usually not a sustainable change. The MD is being reserved for “prescriptions” as this is the one activity in mental health that cannot be done by another provider. As such, diagnosis and all other interventions, are being done by master level clinicians and ‘case managers’ who have less training and have a variable skill set. On the one hand, everyone would agree that the brain is a marvelous and complex organ, yet, on the other hand, helping the brain seems to be the work of simple interventions. That makes no sense.