Turn and Burn
An interesting letter came home in Jani’s backpack the other day, addressed to the parents of the SDC 5 Program (the Newhall School District’s code number for the special day classes that constitute the “ED” or “emotionally disturbed” K-6 student population in the Santa Clarita Valley, the same student population that the Jani Foundation provides free social events for). It was from two Marriage and Family Therapist Interns (MFTI), introducing themselves to the parents of the SDC 5, offering a non-specific “variety of complimentary speaking engagements and educational materials.” They say that although they spend many hours in private practice, they would also like to give back to the community through “our” local schools.
In reaching out to the Newhall School District office, we have been asked to focus our energy towards the SDC 5 Program at Old Orchard Elementary. We understand that your families (notice the shift from “our” public schools above to “your” families in this sentence) have a multitude of needs and we are very excited about the opportunity to help out in the best way we can. Our services focus on mental health and wellness for families with students in the SDC 5 Program, and are offered as an adjunct to existing mental health services within Old Orchard Elementary. Attached to this letter is a list of topics of interest. We are asking families to mark off 5-7 topics that would be of most interest to learn more about…
First, let me say I think these individuals’ hearts are in the right place. I am in no way disparaging their offer. ED students need all the attention they can get. Since they claim to specialized in “mental health and wellness” (I hate that term but will get to that later), I eagerly flipped the page to see what the topics would be. They are as follows:
Behavior Management without punishment
Relations (not sure what they mean by that)
Anger
Anxiety
Fears
Belonging-Rejection
Balancing your needs as a parents vs your child’s needs
Strengthening your Marriage
Strengthening Boundaries
10. Siblings
11. Managing Stress
12. Procrastination
13. Divorce
14. Impulse Control
15. Loss and Grieving
16. Feelings of Unfairness
17. Low Self Esteem
18. Peer Pressure
19. Relationship with Parents
20. Bullying
21. Depression
22. Transitions
23. Self Downing (not sure what that means, either. Being down on yourself, maybe?)
24. Guilt
25. Performance and Competition
26. Feelings of Unfairness (again. I assume that was a mistake).
With all due respect to these future MFTs, this list of issues aren’t mental illness, with the exception of “impulse control” and “depression.”
That’s just life. Normal “sometimes things can be a little shitty” life. Things that happen to all of us.
Is that what MFTs are being trained that mental illness is? Emotional problems caused by the general environmental stress that comes from being human?
Maybe not. After all, they didn’t say “mental illness.” And I don’t blame them. Those words have stigma and not every family in SDC 5 has accepted that their child has a mental illness so if you are trying to reach them, maybe those words aren’t good ones to use. “Mental health and wellness” is more palatable if you are in denial. As I said before, though, I hate the term “mental health” and/or “mental health and wellness.” First of all, it makes mental illness sound like a Kaiser Permanente commercial: “We believe in fruits, vegetables, taking the stairs, and mental health and wellness. Be well and thrive.” But the main reason I hate the term is that it, perhaps inadvertently, minimizes mental illness. Instead of being the potentially life threatening and certainly life-destroying disease that it is, “mental health” makes it sound as harmless as being a few pounds overweight.
I realize that this is part of a larger turn in American medicine to “preventative medicine,” essentially trying to prevent later illness by encouraging healthy “habits” but they don’t say this crap about cancer. No, it’s “StandUp2Cancer” plastered behind the batters during the Major League playoffs. Cancer is apparently something that you fight while mental illness is about making healthy choices, having a salad for lunch instead of schizophrenia.
The upshot is that “mental health” ignores the worst cases of mental illness, the worst of the worst, those who have little to no ability to function so long as their mental illness is untreated.
But treatment, you see, is the crux of the issue. “Mental health” has been pushed by the “consumer movement” for twenty plus years now and has become the primary influence on public policy regarding mental illness. Community based, non-medical, options that do nothing for those most likely to take a bullet from a cop because, while in a psychotic state, the words, “Police! Stop the car!” mean nothing.
Do you “consumer movement,” encourage the mentally ill to resist medication and teach them to how to fight involuntary holds, get them out of the hospital and back on the street, making them think homelessness or jail is a viable “life choice” people think the politicians listen to you because you are right? Because your methods are actually good for those with mental illness? Because you really help people?
No. They don’t care whether your methods are sound or not (except for the NIMH-they are starting to push back).
They listen to you because your methods fit are an inexpensive “fix.” Your agenda fits quite nicely into their need to save taxpayer money.
Same with the insurance companies. They would rather pay for ABA over inpatient treatment because the ABA is going to be done by someone making nine bucks an hour over a full medical staff that costs about three grand a day, and that is just for room and board.
It’s all about the money in America. This is why I find the fears of the functionally mentally ill that they will be locked up due to hysteria over mental illness and violence somewhat funny. Who is going to pay to lock you up? Seriously. It would cost a fortune to keep you strapped down and doped up on Thorazine. It’s much, much, much cheaper just to send you to prison when your lack of impulse control because you are off your meds causes you to commit a crime. We don’t lock up the mentally ill in America until they commit a crime. Prisons are the new American psychiatric institutions.
That, and schools.
I can’t speak for the rest of the world but America has made so many cuts since the early 1970s that there is no chronic mental health system left here now. Most states, like California, have no state psychiatric hospitals left. The few states that do are badly underfunded and facing the budgetary axe.
Because mental illness is the most expensive chronic illness that exists. With every other illness, either you will get better or you will die. Either way, the insurance companies and Medicaid get off the hook. But not with mental illness. They know they will paying for treatment for the rest of your life, which, with the proper treatment can be a long and happy one. Except that long and happy lives for the mentally ill are massively expensive to maintain, largely because they require fairly frequent inpatient hospitalizations.
So the solution is to limit the number of inpatient beds and, should you be lucky enough to get your child in, limit the time as much as possible. I call this “turn and burn” psychiatry, after the business model of low-fare airlines like Southwest, for whom the key to profitability is to keep the planes in the air as much as possible. Hence, when a Southwest flight arrives, the ground crew “turn and burn” to get it unloaded and reloaded and out again in less than 20 minutes, allowing every Southwest aircraft to fly 12-15 legs per day. The phrase itself has two origins: one coming from the restaurant industry, referencing the need to get a large table of people who aren’t spending any money out; and from military fighter pilots, who after expending all their ordinance, “turn” for home and “burn,” lighting the afterburner. Both are appropriate to the treatment of severe mental illness in inpatient hospitals, except they call it “stabilization.” Take the patient only if the patient meets strict criteria for admission (is an immediate threat to themselves or others and even then only if a bed is available), start a medication regimen, and at the first sign of reduction of acute symptoms, release back into outpatient care before insurance or Medicaid pulls the plug on authorizing payment for further inpatient days.
It would be like getting someone who is having a heart attack, getting them out of immediate cardiac arrest, and sending them back out the door to monitored in the community by organizations and individuals who don’t have an EKG machine and wouldn’t know an irregular heartbeat from a hole in the ground.
That is how the mentally ill are treated in America, if they are treated at all.
The first social worker we ever had at UCLA, who is now retired, told us that in 1980 the average inpatient stay at UCLA was one year.
ONE YEAR.
Now the average is 3-5 days, with UCLA being toward the high end of that average.
The “decision” to put either Jani or Bodhi inpatient is never easy, even when Bodhi is hurting himself. Hell, he drove his head into the wall so powerfully once that Susan called 911. They came, took one look at Bodhi, who was still conscious, and then left. The point is that as a parent of a severely mentally ill child, you stall and stall and stall before heading out to the ER while you rush to the doctor at the first sign of a fever. You seek medical attention immediately for the normal aches, pains, and snivels of childhood yet have an internal battle with yourself when your child is trying to bite his own fingers off or, in the case of another girl I know with child onset schizophrenia, attempting to gouge her eye out with a pencil.
Let me explain. It’s not that you are stupid. Quite the opposite. You know how the “system” works and that is why you are stalling. First, you know you are headed for the ER, assuming you actually live in an area that has an ER and a psych ward in the same building like UCLA. And it ain’t like they will rush your child up to the unit. No. You are looking at 12 hours in a tiny room, if you are lucky. If you are not, it will be the hallway or even longer (I’ve known parents who rolled over a full 24 hour period in an ER). And it will just be you trying to keep your child safe in a place with hard floors and walls. It’s not like the nurses or the security guards are going to help you. It is just going to be you, trying to save your child’s life, for hours and hours and hours. And this is before you even get a psych consult. Sometimes, in good hospitals like UCLA, the ER doctor comes in and gives your child whatever cursory examination your child will allow. Your child is physically fine. They never seem to make a big deal out of the bruises and scratches on them. But, I suppose, internally they are fine. Heart and respiration is normal. Nothing to get excited about. And then the ER doc leaves and usually never returns (to their credit, at UCLA, whenever there is a shift change the new ER doctor always checks in).
While you are trying to keep your child from killing themselves, you are also wondering, in the back of your mind, whether your child will even get admitted. Psychosis goes in and out like the tide and your child might just happen to be calm right around the time the on call psychiatrist shows up. Not to mention you are so exhausted by this time you are barely articulate. Honestly, by that point you just want it to end. Either admit my child or let us go home. Even if your child is still in the grip of psychosis, will there be a bed available?
In America, there is a massive shortage of inpatient psychiatric beds. It is bad for adults and even worse for children as many psych units won’t accept anybody under the age of 12. If the child needs to be hospitalized, the psych doctor is supposed to order a hold until a bed opens up but this often doesn’t happen. In fact, there are even organizations pushing states to do away with the mandatory ER psych hold, even though this hold can be the last thing between a person in a psychotic state and something very, very bad happening.
And then there is this: even though your child is banging his head and biting himself, do you really want to put him or her through 12 plus hours in a tiny room in an ER? Especially knowing that he or she might not get admitted? Especially knowing that even if he or she is admitted, he or she will be released back home even though they still have no ability to function in the real world (because they tend to do better in an inpatient setting where there is medical staff that rotate in and out every 8-12 hours?) The hospital, even the best ones like UCLA, do not and cannot match the stressors of the real world. So your son or daughter does a little bit better and before you can even analyze if the medication might be working you get the call that your child is being released that afternoon.
If your child was having what paramedics call a “major medical issue” (ie, heart problems, appendix, whatever), you would never delay. You would never have to decide whether or not to try and get your child inpatient. You would just do it. Yet even though you know your child is in crisis and needs inpatient, you will go back and forth with yourself, trying to decide if you really need to take them this time or whether you think you can tough it out and get them trough it.
Is it really necessary? This is the question you will ask yourself over and over again when you have a mentally ill child. And you always know the answer. You wouldn’t be asking if you didn’t. You are asking because you know what the system will put you and your child through. And it they will probably come out no better than they went in, no more functional, no more safe.
The MFTis talk about a “multitude of needs,” but there is really only one. Can you help me when my child is psychotic and harming themselves or others? Can you help me get them inpatient?
I’m sorry, no.
That’s not on the list.
