In a previous column,1 I noted that 2019 marks the 100th anniversary of the founding of the Austen Riggs Center. In that column, I described the history of Riggs and how Riggs has come to stand for a comprehensive and intensive way of working that has an impact on the field well beyond the 150 patients we treat annually.
Riggs specializes in work with patients with complex psychiatric illnesses which are sometimes referred to as “treatment-resistant,” although we believe the resistance often lies less in the patients’ illnesses than in the limits of our treatments or of ourselves as treaters. The treatment program emphasizes the dignity and voice of our patients, who are asked, in our fully open setting, to balance freedom with responsibility. We believe that our open doors open minds. Our psychodynamic, biopsychosocial approach to treatment is undertaken in a residential and intensive outpatient setting built around a therapeutic community program also offering individual intensive psychodynamic therapy (PDT) 4 times weekly, medications, family work, and other modalities. This integrated, resource-rich, and idealistic treatment approach places Riggs at the intersection of contemporary psychoanalysis with mainstream psychiatry, psychology, social work, and nursing.
In this column and several that follow, I will summarize learning gained from the Riggs Centennial Conference on September 21 and 22, 2019, which had the ambitious title: “The Mental Health Crisis in America: Recognizing Problems, Working Toward Solutions.” The sold-out conference convened an unusual group: leaders of American psychiatry and psychoanalysis, clinicians, social policy advocates, health care attorneys, and local clinicians and social service providers, with an international perspective from the United Kingdom, also included. Our tasks were to build bridges between divergent perspectives, break down silos, and deepen mutual understanding as we explored problems in 2 domains—(1) problems gaining access to care, and (2) problems with the care provided even when there is access—and then to begin to propose solutions. Each of the 3 half-day modules of the conference included several shorter presentations followed by a longer keynote address, then a panel discussion among speakers and panelists and then with the audience.
FRAMING THE PROBLEMS
The first half-day module began by noting that there was much to be proud of in contemporary mental health care. Many patients and families are working to achieve recovery, and seriously dedicated clinicians and researchers are at work in the public and private sectors. Professional organizations are working to develop optimal practice guidelines and support access to care. There are high-quality programs like Riggs and others. As a nation, we have increasingly come to recognize that “There is no health without mental health.”2 Commendable advocacy strives to reduce stigma, and we have seen the passage of the Mental Health Parity and Addiction Equity Act and the Affordable Care Act (ACA), while, at this writing, the bipartisan Mental Health Parity Compliance Act is moving through both houses of Congress.
However, there are also serious problems.
- The Centers for Disease Control and Prevention (CDC) reports a 33% increase in suicide in the United States from 1999 through 2017, while suicide is decreasing elsewhere in the world.3
- According to the National Institute for Mental Health (NIMH), <50% of people with mental disorders received any treatment in 2017, and only 60% of those with serious mental illness (SMI) did.4
- A national problem with gun violence has been unfairly linked to mental illness when those with mental illness account for only 4% of gun violence.5
- There has also been an explosion of substance use concerns, including:
- An iatrogenic opioid crisis.
- Rapidly expanding the use of ketamine for depression, while it remains unclear whether ketamine’s apparent benefits are primarily because of its opioid receptor agonist effects and whether discontinuation of ketamine is associated with an increased risk of suicide.6
- The growing use of cannabis or its derivatives (eg, cannabidiol) as agents of “wellness,” while most use of cannabis for alleged medical purposes is far ahead of the science to support the claims made, although cannabis is known to double the risk of psychosis.7
- Vaping causing lung injury and death in teens and others.
- Jails and prisons are the “new asylums”; 15% to 20% of inmates have SMI.8
- Growing recognition of the importance of “health disparities” and “social determinants of health.” It has been said that “Your zip code reveals more about your health status than your genetic code.”9
- Chronic underfunding of mental health treatment and research.
- Incomplete implementation of the Mental Health Parity Law 11 years after it was signed into law.
- Efforts to undermine the ACA led in 2018 to the first increase in uninsured individuals in the United States since the ACA was implemented.10
- The limited treatment goal of crisis stabilization, the focus of insurance entities and managed care, is often substituted for real treatment that pursues the widely accepted goal of recovery.11
EXCESSIVE RELIANCE ON A BIOMEDICAL MODEL
In addition to all of these areas of concern, there are problems with our clinical models, including an excessive focus on the biomedical at the expense of the biopsychosocial—and despite growing evidence to the contrary. Studies such as the STAR*D trial teach us that over 75% of our patients present with the kind of comorbidity or suicidal ideation that would exclude them from randomized trials of medications or therapies, while this majority of patients with significant comorbidity shows significantly lower response and remission rates to so-called evidence-based treatments.12 Real patients are considerably harder to treat than those in randomized trials—where, for example, in depression, the placebo effect can account for as much as 75% of an antidepressant drug’s apparent efficacy.13
The Collaborative Longitudinal Personality Disorder Study (CLPS) teaches us that borderline personality disorder (BPD) “robustly predicts” the persistence of major depression.14 BPD is known to be highly prevalent, yet it is often undiagnosed. The mainstay of its treatment is psychotherapy, according to the BPD Practice Guideline published by the American Psychiatric Association (APA). It is not an exaggeration to suggest that, among mood disorders that lead to SMI, BPD puts the “S” in SMI.
Our diagnostic system has serious limitations, too. The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) is the culmination of a thoughtful and earnest effort to categorize Kraepelinian diagnostic categories, but few or even no specific genes are associated with these diagnostic categories. For example, there are over 200 single nucleotide polymorphisms associated with schizophrenia, several dozen with major depression, and considerable overlap between single nucleotide polymorphisms associated with multiple mental disorders.15 The late 20th-century expectation that decoding the human genome would lead to discovery of the genes that cause mental disorders has not borne fruit. Without the careful delineation of diagnostic categories from DSM-III to DSM-5, we would not have learned that the heritability of the Kraepelinian diagnostic categories that are familiar to clinicians is polygenic and complex. Nor have we found biomarkers for mental disorders, while we have learned that early adverse experiences are “enviro-markers” that predict medical, mental, and substance use disorders and even early death. Far from nature proving more important than nurture, we have learned that they work synergistically. Genes=disease has instead become gene-by-environment interaction=disease … and health.15 Arguably, gene-by-environment interaction is just another way of saying “biopsychosocial.”
Recognizing the polygenic heritability of mental disorders, that most patients have multiple disorders, that the brain “connectome” is similar across mental disorders, and that we tend to use the same 75 or so medications for all disorders, Caspi et al16 were the first to report what has now been replicated—that there is a single “psychopathology” factor called “p” that underlies vulnerability to most mental disorders, and that p is a function of central nervous system developmental adversity, heritability, but also early and recent social adversity. It is, hence, no surprise that we have seen other efforts beyond the APA’s DSM emerge to pursue a diagnosis, such as the NIMH Research Domain Criteria (RDoC) system17 and the Hierarchical Taxonomy of Psychopathology (HiTOP) model.18
PROBLEMS IN THE DOMAIN OF PSYCHOTHERAPY
Although some of these problems relate to an overemphasis on a biomedical perspective on mental disorders, there are also problems in the domain of psychotherapy. There has been a proliferation of alphabet soup “manualized” therapies for specific disorders [eg, dialectical behavior therapy (DBT), cognitive behavior therapy (CBT), psychodynamic therapy (PDT), transference-focused psychotherapy (TFP), mentalization-based therapy (MBT), eye movement desensitization and reprocessing (EMDR)]. This line of research has followed the now known to be flawed notion that patients have single disorders that will respond to single evidence-based treatments targeting those disorders.15 Unified protocol transdiagnostic research in CBT teaches us that patients with anxiety disorders do just as well with a single unified form of CBT that targets underlying neuroticism and other factors as they do with anxiety disorder-specific CBT.19 Psychoanalysis, of course, was the first transdiagnostic “unified protocol” therapy focused on underlying factors rather than surface symptoms, but its self-defeating aversion to aggregate data research worked against its credibility.
Shedler20 summarized the effectiveness of short-term therapies by noting that “They don’t work for most patients most of the time.” In treatment as elsewhere, we may be attracted to the notion that “less is more,” but it turns out that more is indeed more in therapy, as is so often the case elsewhere in life. We are learning that it is the relationship between therapist and patient as manifest in the therapeutic alliance that seems to matter most in determining the outcome of therapy, regardless of school of therapy.21
Although CBT has led the way in research output, PDT has demonstrated its equivalence in head-to-head comparisons.22 Sometimes competition between schools of therapy is described as a horse race. We look on as spectators watching to see who wins the race with the most studies or best results. Sadly, an equally apt metaphor for the competition between schools of therapy is that of a circular firing squad. Arguments and petty tensions between proponents of different schools of therapy risk diverting the attention of those who recognize the benefits of psychotherapy from the more important task of speaking in a common voice to the larger biomedically focused world about the importance of psychotherapy. It was recognition of the danger of such circular firing squads among psychotherapists that led some of us to create the Psychotherapy Caucus within the APA—a “big tent” group that brings together psychotherapists from multiple perspectives to increase the recognition, teaching, and practice of psychotherapy among psychiatrists.
We are wise to avoid circular firing squads, but we also need to call out bias when we see it. In an earlier column, Abbass et al23 described bias against PDT. He and his colleagues listed elements of this bias:
- Exclusion of PDT researchers from funding and guideline committees or faculty positions.
- Exclusion or distortion of PDT evidence in practice guidelines.
- Distorted depictions of PDT based on caricatured or outdated versions.
- Research use of distorted PDT that is intended to fail.
- Biased study selection in meta-analyses based on researcher allegiance.
Such bias contributes to bad patient care and bad science, and it undermines the credibility of all psychotherapy research. Abbass and colleagues suggested a way forward that includes (1) “adversarial collaboration,” in which adherents of different schools collaborate in comparisons of different schools of psychotherapy, (2) research on “shared elements” of psychotherapy regardless of school—an approach favored by the National Academy of Medicine (formerly the Institute of Medicine),24 and (3) balanced inclusion of relevant research perspectives in committees that assess research findings, develop practice guidelines, and determine grant funding.
Jane Tillman, a suicide researcher who is the director of Riggs’ Erikson Institute for Education and Research, deepened our discussion of suicide in her talk at the Centennial Conference. She described the interpersonal theory of suicide, in which thwarted belongingness, perceived burdensomeness, and development of the capability for suicide contribute to the act.25 Tillman also introduced 4 Rs that may protect against suicide: relationships, resilience, reasons for living, and restriction of access to lethal means. Fostering these protective factors mitigates the isolation, thwarted belongingness, and perceived burdensomeness that predispose to suicide. Social networks, caring relationships, and family support all play roles in supporting reasons for living and resilience.
Given that over half of suicides involve firearms, that we do not see substitution of suicide method if access to one method is restricted, and that states with stricter gun control laws have fewer suicides, Tillman noted that restriction of access to firearms is the single most significant public health step we could take to reduce deaths by suicide. Achievable ways to pursue this goal include working with gun sellers and owners to increase education about gun safety, limiting access to firearm purchases through waiting periods, and “extreme risk protection orders” through which guns may be confiscated during periods of identified risk.
Tillman reported converging findings from 2 separate studies of suicidal patients at Austen Riggs. Carried out over a decade apart, the studies, using different methodologies, suggest that 70% to 75% of previously suicidal patients were recovered from suicide behaviors at an average of 7 years after admission.26 These results, which suggest the importance of relationships, community, and a sense of belongingness in fostering resilience and moving people away from suicide, were the first of a number of times in the Centennial Conference when the kind of relationship-and-community-focused model of treatment used at Austen Riggs appears to offer a contribution to solving problems in the larger world.
A VIEW FROM THE SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES ADMINISTRATION (SAMHSA)
In her presentation, Anita Everett, MD, Director of Mental Health Services at the Substance Abuse and Mental Health Services Administration (SAMHSA), described the mental health treatment system as a metaphorical “black box.” She described “front door” problems gaining access to the black box of treatment. Health disparities and social determinants of health play a major role in problems with access to the front door of the mental health system, as do long waiting lists when one seeks care. Once through the front door, though, there are limitations inside the black box of treatment, with a focus on diagnoses and checklists failing to provide an adequate perspective on the problem or to foster caring relationships. Too often limited treatments are offered by an insufficient workforce. There are also “back door” problems, with poor continuity of care and high treatment dropout rates.
Local leaders in social services and provision of community mental health, Colleen Holmes, president and CEO of 18 Degrees (a Berkshire County nonprofit serving children and families facing health and social disparities) and M. Christine Macbeth, president and CEO of the Brien Center for Mental Health and Substance Abuse Services (the Berkshires’ community mental health center) offered perspectives as panelists on local manifestations of these problems and their link to social determinants of health.
KEYNOTE BY TOM INSEL
The conference’s first keynote address was given by Tom Insel, past director of the NIMH, cofounder, and president of Mindstrong Health, and current “mental health czar” in California. For Insel, participating in the conference was a homecoming. He described his experience in the 1970s as a medical intern at nearby Berkshire Medical Center, where he had his first learning experiences about community mental health at the Brien Center, and spent time attending case conferences and receiving supervision at Austen Riggs.
Insel offered a wide-ranging and far-reaching keynote. He added his own perspective on the crisis in mental health. For example, since 1995 there have been dramatic reductions in mortality due to stroke, heart disease, human immunodeficiency virus/acquired immunodeficiency syndrome, and childhood leukemia, while deaths by suicide have increased substantially. In fact, while deaths due to “diseases of despair” (suicide, drug overdoses, and alcohol-induced liver disease) have declined in the rest of the developed world, they have increased in the United States.27
As a biomedical researcher and later as director of the NIMH, Insel hoped that the study of the brain would “bend the curve” in mental health treatment. However, spending billions of dollars on brain research over a couple of decades did not improve outcomes. Perhaps, in another 30 years, it will do so. Insel next moved his career to Silicon Valley, hoping the answer might lie in big data, but here, too, this was not enough to bend the curve. What Insel calls digital phenotyping may play a role, in that the big data collected from smartphones is highly predictive of who is in trouble, but the information is detached technology outside any relationship between the patient and a community of care. He suggested that the care he saw provided back in the 1970s in Berkshire County seemed as good as or even better than the care available now. He came to recognize that, with problems as complex as those that lead to mental disorders, there is no single magic bullet to solve the problem.
What Will It Take to Move From Problems Toward Solutions?
Anticipating the rest of the conference, Insel began to offer some ideas about solutions. From a medical perspective, he suggested the ultimate solution would be complex, involving neuroscience, genomics, and information technology, but also the improved engagement of the individual identified as the patient. One essential ingredient will be measurement-based care. He quoted “superforecaster” Philip Tetlock: “If you don’t get feedback, your confidence grows much faster than your accuracy.”
Insel spoke of the role of what he called the 4 Ps as part of a medical approach to bending the curve of outcomes. The 4 Ps refers to predictive, preemptive, personalized, and participatory care. Predictive refers to identification of risk factors for mental disorders; preemptive refers to measures that move upstream and work to prevent full-blown disorders through early intervention; personalized refers to individualized interventions that are based on an individual’s unique biology and psychosocial context; and participatory refers to maximizing engagement through shared decision-making with patients.
He also identified 4 Cs as crucial psychosocial components in bending the curve: cognition, connection, commitment, and compassion. These refer to the importance of psychoeducation, social connections, a sense of purpose, and compassionate relationships—with individuals and within a community—as part of bending the curve in mental health outcomes. Provision of such care should be integrated with the provision of primary care, be patient-centered, involve the family and community, and be reimbursed at rates that recruit and retain providers.
Hence, Insel recognized that, whatever is the ultimate optimal system for the provision of treatment, relationships that continue over time and that contribute to a sense of belongingness and community will play a prominent role. This theme of the centrality of relationships and community forms a link with central components of the treatment program at Riggs. New solutions will require a “back to the future” recognition of the importance of these psychosocial elements of treatment.
In the next column, we will address more fully the nature of solutions to problems identified in the first module of the conference. Saturday afternoon focused on how we can find hope through engagement in addressing problems related to limitations in clinical models of care, while Sunday morning addressed top-down legislative and bottom-up legal approaches to improving access to care.
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