Virgil reflects on the mental health crisis in America

Updated: Nov 11, 2019


In the following post, I amble through a forest of wisdom I have recently observed in others. While observing their differences I have also seen that most are woven into a common theme: restoring a sense of community, belonging, connectivity, engagement, and relationship. These elements are critically important to the process of healing not only mental and emotional illness and dis-ease, but also the process of healing our planet and our politically divided nation.

My life’s vocational mission has been to help create healing therapeutic communities (nonprofit, residential treatment centers) within which the best of scientific, clinical interventions can be woven and individually aligned to help mentally ill individuals achieve and sustain their highest levels of functioning and fulfillment.

My life’s avocational mission has been to live within and support a loving family where I see our four children and their spouses (Lis and mine) also fulfilling their missions by weaving their own tapestry of healing relationships into their families and communities. As I accompanied some of our grandchildren in their protest of the climate crisis a few days ago, I could see that they, too, are launching their missions. (However, I hope that play and education are still the primary pursuits of our grandchildren at this point.)

Vocationally, my work is not yet over. My ‘retirement’ work (Virgil Stucker and Associates LLC (VSA)) is building a virtual healing community through therapeutic consultation. We help families navigate the mental health system for a loved one and help mental health leaders launch and support their own healing communities while also helping them to survive and thrive in their arduous yet fulfilling roles as leaders. This includes shining light on current leaders through our podcast Mental Horizons. Of course, I love that Stephanie, our youngest daughter, is my partner in the new phase of work. I am so proud of her creative leadership and commitment to this new mission.

On my mind is the mental health crisis in America.

Over the last two weeks I have had conversations with psychiatrists who are co-creating solutions through nutrition and new medication combinations. I have also read Mind Fixers - Psychiatry’s Troubled Search for The Biology Mental Illness by Anne Harrington, who helps us not to throw away current biological options even though they may be ‘troubled’. The day after finishing her book, I attended the Austen Riggs Center centennial conference, The Mental Health Crisis in America: Recognizing Problems, Working Toward Solutions (slide presentations from amazing thought leaders are on their website).

There is no narrow, singular mental health solution; in fact, all such approaches are flawed. There is also no genetic solution or perfect pill around the corner.

If we recognize that mental and emotional dis-ease arises from or creates a dis-engagement from one’s relationship with family, community and self, then we can begin to see how an array of mental health care options can be woven together into an individualized plan for improving the process of re-engagement and recovery.

We see the highest levels of re-engagement occur when one’s recovery plan is implemented within the healthy structure of a healing or therapeutic community where they are cared for by family, peers and professional caregivers. This may occur within a residential treatment center or though a comprehensive linkage of ‘outpatient’ services.

I believe that any scientific or clinical intervention that is offered to someone with mental illness will be most successful and have sustained results if it is delivered by someone who is able to maintain an authentically caring relationship with them. This has been verified by research about the impact of the ‘placebo effect’. Within a therapeutic community, this may be known as ‘milieu therapy’.

Recognizing the vulnerability of someone with a mental illness, we need to believe in them even when they may not believe in themselves. Often times we even need to walk with them amidst the noise of their delusions and disbelief and accompany them to the edge of the abyss.

We are ‘present’ to accept their authentic self as it emerges and to support their recovery with our professional mental health interventions and with our love.

As vitality outshines their vulnerability, we co-create plans, goals and structure with the person of concern. A re-connected life meaningfully engaged in community begins to resume.

THE FORMULA FOR A RECOVERY PLAN: TWO QUESTIONS

THE FIRST QUESTION

What are your symptoms (impediments to engagement) and what is your diagnosis?

Clinical interventions are best collaboratively selected individually, not ideologically, from the categories below (not all of them!). Each is aligned with the relevant symptom(s) with the understanding that none is a cure.

Psychopharmacological or biochemical interventions

  • ​Standard psychotropic medications for mental health symptoms

  • Medically assisted treatment (MAT) for substance use disorder

  • Innovative psychedelic options

  • Ketamine

  • Genetic (not yet an intervention except to match medications with metabolism)

Psychological

  • Individual psychotherapy

  • Group psychotherapy

  • Family therapy

  • Milieu therapy (achieved by engaging in a healing community)

​Neuroscience or electromagnetic

  • Neurofeedback on one end of the invasiveness spectrum with ECT on the other, with TMS in the middle

Nutritional counseling for improved brain health

  • Five levels of nutritional psychiatry

  • Ketogenic diet as a medically ‘prescribed’ intervention for improving brain health

Integrative Physical Health Interventions

  • Exercise routine for brain/body health

  • Physiological assessment and treatments of physical ailments, which may trigger mental health symptoms

  • Assessment and treatment of pain, which may be ‘real’ but found to be psychosomatic with no real physical cause.

  • Complementary modalities such as m​assage therapy, yoga, Qi Gong for overall wellness, and mindfulness training

Where (from whom) are these Interventions best obtained? Answers to these questions are based on the complexity and acuity of the person and help to clarify where on the continuum of mental health care optimal results can be achieved.

THE SECOND QUESTION

What is your dream?

Over the years I have asked this question of hundreds of individuals; sometimes the response is puzzlement with phrases like “I don’t know, no one has asked me that question for a long time. They more frequently ask, what is my diagnosis?” As I continue this dialogue with them, I have sometimes felt like an archaeologist in search of treasure. Most often a glimpse of a dream emerges and, as it does, the person’s voice grows stronger.

Their answer is expanded through continuing dialogue into core goals and objectives associated with plans for implementation. Therapeutic communities may provide access to work and educational activities as a part of the recovery process to help individuals clarify their dreams and activate their awareness that they can actually lead meaningful and purposeful lives. For those who do not need the residential support of therapeutic communities, a coach or mentor may also be a helpful ‘intervention’ to assist them with meeting goals.

SUSTAINABLE RESULTS FROM THE RECOVERY PLAN

  • The person experiences, first, a greater sense of belonging in the world,

  • A restored capacity for maintaining relationships,

  • A greater sense of purpose and meaning (related to education, work and fulfillment activities), and is

  • Continuously learning and using skills that will help him or her not to be derailed when symptoms arise again.

The importance of these three attributes of recovery was validated by 10 years of qualitative research in my last therapeutic community CooperRiis. In a recent podcast with Elyn Sacks about her famous life story, she also emphasized the importance of these elements in her own recovery.

Over the last few weeks, at conferences and in various interactions, I have encountered several wise individuals and have been sorting out what I have learned from them. My framework of understanding is the recovery planning ‘formula’ that I have described above. Below is a list of some of those wise individuals.

Chris Palmer, MD at McLean Hospital and Harvard Medical School.

Through our daughter Stephanie McMahon’s podcast with Chris and subsequent conversations with him I have begun to understand that nutritional psychiatry may help the person with mental distress to experience improved well being and a healthier brain. The highest level intervention is the ketogenic diet which literally energizes the brain and calms psychosis for some. Chris’ research and protocols are still in process and we will follow his progress closely. I had no idea that a diet rich in fat could energize your brain and help you lose weight.

Rocco Marotta, MD, at Silver Hill Hospital.

Dr. Marotta strives to help individuals with persistent psychosis. We know that Clozaril can often help, even though it can also be physically harmful. ‘Rocky’ notices also that while it helps to curb active symptoms, the person is still too frequently left inactive, unmotivated and disconnected. He has found that by adding oxytocin (the ‘love’ hormone) and sometimes NuVigil to their regimen that his patients become more active, motivated and connected. I sense that his genuine sense of caring also plays a role! (Please let me know if you would like a copy of his publication of case studies.)

Anne Harrington, professor at Harvard and author of Mind Fixers.

During the last decade my understanding of biological psychiatry was deeply impacted by Robert Whitaker’s Anatomy of an Epidemic, which was published in 2010. It assembled information that criticized and condemned pharmaceutical companies and the use of psychiatric medications… and provided no way forward for people who still found that their personal recovery relied on some use of psychotropic medications. Anne’s book is based on the same information contained in Bob’s but she provides a way forward. She acknowledges that psychiatry and pharmaceutical firms have provided only highly imperfect biological options (not solutions), while helping us to see that these options may still be woven into a person’s plan for recovery… as part of the puzzle, not a cure.

Anne Harrington’s review of both history and contemporary efforts shows there is indeed no singular cure being provided by any practitioner.

She tends toward endorsing the importance of community acceptance and inclusion, which are dear to my heart.

Then comes the Mental Health Crises in America conference at Austen Riggs. I waded into a weekend of conversations with world-class leaders about the “Crisis” and several speakers seemed to zero in on the healing value of therapeutic community.

I heard Carol Gilligan, PhD give the keynote and bought her new book The Crisis in Connection. Peter Fonagy, PhD well-known for his ‘Mentalization’ techniques, flew in from London to give a keynote to us about a core feature of mental illness being “the pervasive absence of trust”.

In multiple conversations during the conference, I began to feel that my life’s work of establishing residential therapeutic communities may have prepared me to add more value to current, emerging ‘connection or relationship building’ efforts to address the Crisis. I was urged to write a book.

Anita Everett, MD, the Director of the Center for Mental Health Services at SAMHSA (and former president of the APA and AACP), who identifies as a ‘community psychiatrist’ said the “majority of people with mental illness rely on Medicaid and Medicare”. Anita is ideally situated in her current director role to have significant impact on the Crisis.

Here are some of her startling observations and facts:

  • She sees that we are now in the Fourth Era of Recovery and Rapprochement, (a restoration of harmonious relationship?) between those in distress and caregivers, including rethinking how we are using inpatient care.

  • The First Era of Mental Health Care, Anita describes as the Dark Ages before 1800.

  • The Second Era of Institutions and Asylums was from 1800-1963.

  • The Third Era was the Build Up of Community Care, informed largely by President Kennedy’s Community Mental Health Center legislation which he signed in 1963. The full hope of this legation was never fulfilled; hospitals were closed and many mentally iil individuals ended up being homeless or in prison.

  • Now, the hope of the Fourth Era of Recovery and Rapprochement has emerged in the midst of crisis

The “Front Door Problems” of the mental health crisis in America:

  • The US had 46 million people with mental illness; 25% of these with serious mental illness.

  • Of the 46 million, 20% receive treatment

  • Of the seriously mentally ill, a little more than 50% receive treatment

  • 47,000 die by suicide each year, on par with opioid deaths

  • Life span in US is shorter now because of these deaths.

  • The ‘Front Door’ is too often closed because of prolonged waiting periods. There are not enough professionals and not enough use of EMR (electronic medical records) which speeds the making of appointments.

  • ER departments are still a primary ‘front door’ and they are frequently filled with patents waiting for a bed. Mental Health Crisis Centers are growing in numbers.

The "Black Box"; even when they get beyond the ‘front door’ into the black box of treatment there are many impediments.

  • A diagnosis is developed but it doesn’t give us much useful information.

  • Hugh problem with how we formulate a whole picture of a person… check lists don’t work.

  • Treatment approaches are highly variable. What is the person actually getting? We don’t really know what treatments work best.

  • Suicide interventions are available but variably and insufficiently used.

The "Back door" - what happens when patients move out of treatment… out of the ‘box'?

  • Unfortunately, a lot of people drop out of treatment prematurely and 90% of those are at risk of relapse

  • Also, in the US, when someone is finished with treatment, we generally ‘close their chart’. This is a problem because we seldom follow up and people feel uncared for. This is especially problematic for a person who has made a suicide attempt.

  • We are learning that follow up after an ER visit for a suicide attempt is very helpful… unfortunately, the follow-up seldom happens.

Anita helped us imagine options. For example, in Australia such a person receives a caring post card… this proactive outreach shows the person that someone cares about them.

I look forward to learning more from Anita about how this kind of caring and connection can be built into the current public mental health system. It would seem that the quality of relationship that the simple post card reflects, for example, is a state of mind that really doesn’t cost much to create.

REFLECTION ONE

Here are some pertinent remarks from Jeffrey Geller, MD, Medical Director of the Worcester Recovery Center and President-Elect of the APA (with 39,000 members).

He will begin his presidency in April 2020. Jeffrey has long appreciated the importance of therapeutic communities, which I know of through his love for Gould Farm. He and I had breakfast together at the conference with his friend Carrie Sacco, a nurse who is starting a nonprofit to improve the impact of nutrition on mental health.

Jeffrey told me that one of his main projects for when he is APA President will be to try to help states determine the number of new inpatient beds that are needed. Like Anita, he sees that we need to re-think inpatient beds.