On Sunday, September 29, 60 Minutes aired a segment entitled “Untreated Mental Illness an Imminent Danger?” reported by Steve Kroft. The connection between mental illness and violence is a complex and fraught issue, not easily covered in 13 ½ minutes of primetime television, but the story did aptly describe failures in the mental health system.
Inadequate mental healthcare is responsible for untold human suffering – not only for the sensational mass shootings that prompted the segment, but for homelessness, incarceration, suicide, and countless lives of wasted potential. States are quick to cut their community mental health budgets, abandoning people who are living with serious mental illness to the Medicaid system – a medical plan that is woefully unable to meet their needs. Rather than the integrated psychiatric, medical, and social support that is proven to lead to better outcomes, many people are left to the revolving door of the justice, corrections, and hospital systems. Society pays the price, in real economic costs and in inestimable human costs.
The problem is easy to formulate, but what about the solution? In the present dialogue, it is easy to lose sight of the fact that there are responses in place to the mental health crisis that are working. Sunday’s segment neglected any mention of this, yet in almost 40 states there exist community mental health centers that help people with serious mental illness live productive, fulfilling lives. These centers often struggle for survival in the face of limited support and funding, but they are successfully addressing the problem. People’s concern and understanding of what is possible should be informed by that.
Everyone who weighs in on this issue agrees that ultimately we must expand mental health support services for people living with schizophrenia. My experience as the president and executive director of Fountain House, a world-renowned community mental health program, has taught me that these support services must have a few key features: Early intervention 50% of psychiatric illnesses manifest by the age of 14 and 75% manifest by the age of 24. Diagnosing and treating these disorders earlier means less time lost to the downward spiral of illness and the slow climb back to recovery.
Location Isolation is one of the single largest problems facing people living with serious mental illness today. Even someone who is in mental health treatment may dutifully take their medications, see their providers for a few hours a month, and have little else to fill their life. Frequently these conditions disrupt people’s lives – causing them to lose jobs, drop out of school, and alienate those around them. Discrimination, misunderstanding, and self-stigma only exacerbate that.
Centers in the community – physical locations where people congregate – can help those living with mental illness reconstruct their social networks and build the support that encourages them to move forward with their lives. Proactive outreach People living with serious mental illness are frequently difficult to engage, and mental health recovery is seldom straight line. Any number of things may deter people from seeking or connecting with available help – anxiety, medication changes, and lethargy, to name a few. A persistent outreach effort by a person or team aimed at building a genuine relationship with the recovering person is crucial.
Since 1948, Fountain House has been confronting the social challenges of mental illness and developing a response that includes these vital features. Fountain House serves New York City from its Hell’s Kitchen location, but the inherent humanity, social inclusivity, personal empowerment, and innovation of this approach has inspired its replication around the world and has earned federal recognition in the US as an evidence-based practice. It is the gold standard for community mental health programs, and it is the model for more than 200 programs in 38 states and another 100 programs internationally that successfully address the social impact of mental illness and support people to build meaningful lives in their communities.
Untreated mental illness is an imminent danger, but as the 60 Minutesreport rightly stated, very little of that danger is due to tragedies like the Navy Yard shooting. It is much easier to avert our eyes from the smaller daily tragedies of mentally ill individuals and their loved ones struggling to make their way in an inhospitable world with little or no help. But that help does exist. As a society, we must decide whether we will prioritize making it available to everyone who needs it.
Diffusion is essentially a social process through which people talking to people spread an innovation.
As an intervention in mental health practice, the idea of Fountain House represents all the right values. It is
And yet growth in the adoption of the model has remained stuck at the 300+ mark for over a decade now. Atul Gawande's article in the recent edition of the New Yorker magazine (July 29th) takes on this very problem. He asks why does one innovation in medical practice spread while another languishes, even though they both achieve obvious improvements in healthcare. His solution is that change in practice requires the intervention of coaches who establish personal trusting relationships. "People talking to people is still how the world's standards change," he asserts.
This is exactly what Fountain House did in the 1980's and 1990's to spread its message of hope and humanity in mental health. The training system included the formation of a Faculty for Clubhouse Development, its "university without walls" as Propst (1998) once described it. As a result, Fountain House as an innovation in mental health practice enjoyed an early dramatic worldwide spread.
Gawande is clear about the impact such an approach would have in health care. In order to achieve a system where people routinely are doing X or Y when they are not being watched, he suggested this regimen:
a list of clear practices
regular visits by a personable coach—a decidedly non judgmental approach— that replicates the highly successful seven-visit practice of pharmaceutical salesmen.
In other words, Gawande argues that we approach the diffusion of innovations in institutional healthcare in the same way clubhouses promote the recovery of individual members - through the personal intervention of trusted, nonjudgmental staff coaches. I suggest that what we know to be proven and effective in member recovery can apply equally as well to stimulate institutional growth and expansion—the marketing of the Fountain House brand should be fundamentally based on human agency of motivational coaches. This is the same broad mobilization technique Gawande posits that society has employed to address illiteracy (a public school teaching profession), pain in surgery (anesthesiologists), and agriculture (the extension agent system).
We have standing ready a cadre of capable, clubhouse members who can participate, even lead, in a movement to expand decent community-based support in mental health recovery. In my next article, I will outline what such a system would look like.
Alan Doyle, EdD Director of Education, Fountain House
Gawande, A. (2013). "Slow Ideas," The New Yorker, July 29, 2013, 36-45.
Propst, R.,(1997), Stages in realizing the international diffusion of a single way of working: The clubhouse model. New Directions for Mental Health Services, 74, 53–66. doi: 10.1002/yd.2330227407.
Note: This is the first in a series of articles on promoting growth in the replication of the working community model of psychiatric recovery pioneered by Fountain House.
To make art requires material, expertise, patience and a place to work. None of the ingredients are inexpensive. I’m interested in becoming an art therapist. However, in the least pricy program available in New York City each book runs me about $125 and each piece of art costs at least $250 to make from start to finish. It’s very expensive. It’s too expensive even for full federal and state grants and the little money I get from social security disability to cover the costs of supplies and books.
Luckily there are still ways of getting the help I need to make it through school without incurring serious debt. One of those ways is the Fountain House Scholarship. Every semester for the past two years, I have been taking two art classes and two psychology classes. Applying to the Fountain House Scholarship has allowed me to pay for materials and books needed for my classes on time. I don’t have to worry about waiting until my Tuition Assistance Program (TAP) payment comes through, usually weeks after school starts, to have enough money for all the startup costs. And I get to save my TAP monies for all the projects later in the semester, which normally cost me more because they are the finals I need to do the best on.
Now you may think it’s hard to go to school, and that is true. You may also think it’s hard to apply for the Fountain House Scholarship and go before the review committee, but that is false. School is work. It’s hard, sometimes I want to give up, but I fight through. There are assignments to finish, papers to write, tests to take. It is a full-time job – even when attending college part time. However, the Scholarship application is easy. Name, address, worker, what do you want to take; write a short essay; provide a printout of the class you want to take and you’re done! The interview is easy, too: go before a group of about five people - fellow members, board members, administrators - and talk about what you want to do.
Here’s the hard part of the Scholarship: George Handran, the man responsible for the Sidney R. Baer, Jr. Foundation, who ensures we get our scholarships each year, thanks me for being there. He thanks me for giving me money to go to school by which he can honor Mr. Baer’s legacy. And every time I tear up, and in that moment I know that I have to do my best because Mr. Baer didn’t have the same chances and because I want to set an example for my fellow members. Because someone believes in me enough to hand me $500 to work towards my goals – the ones that doctors told me I was never going to achieve.
This last semester I didn’t think I would make it. It was the first time I had gotten seriously depressed since 2008. A series of deaths in the family, friends getting ill, and my own medical issues overwhelmed me to the point where I was unable to concentrate. My ability to sit in class dwindled and I felt the need to do something to show how low I was. It was at the moment I began to step into a pond at Central Park that I knew I needed help. So I reached out. I contacted the counseling office at school, spoke to my Accessibility adviser, saw my psychiatrist (my medication levels were dangerously low because I wasn’t taking them properly), and met with my worker at Fountain House. This is the first time I’ve been depressed and in college when I’ve had support.
Support doesn’t mean everything was done for me. I still had the autonomy to choose how to get help, but this time I also had people behind me to help me get to my goals. And because I had planned for the return of depression or mania, I had options to choose from. My goals were to save my grades from the havoc that depression wreaks. I spoke with my advisor, and I decided to take incompletes in my sculpture and statistics classes because they required a lot of physical or mental work. I kept taking the two psychology classes because they only required memorization; no projects, papers or heavy physical work. My condition had been documented, so I could do this with no penalty.
This semester I will finish those two classes because I am starting to feel better, and I won’t be getting F’s like I did back in 2002 when I didn’t have the support I do now.
The real lesson is that success is based on what my own idea of success is. For me, it’s getting the best education I can with consideration to my health and well-being. To be true to myself and admit when I need help or need to take some time off. And to know that the entire Fountain House community will be behind me the whole way, no matter what, to help me do my best. The best part of all is that I know George and the rest of the committee will be in that room, year after year, semester after semester, thanking each one of the Fountain House Scholarship applicants for their courage, their hard work, their will to go on, and their ability to give back to the community.
It was my pleasure to sit on the Academic Scholarship Committee on July 29th and 30th and to be a part of the scholarship awards for the 43 deserving candidates. This was my first encounter with Fountain House since I was elected to the Board of Directors. I was so moved by the members and their presentations - students applying for support for single courses, undergraduate programs, MBAs, and PHDs.
These people were awesome! They presented articulate, well thought-out essays and spoke knowledgeably about their goals. Many are faced with adversity, lots of "red tape" with the larger system, and they are willing to plow through for something bigger. It was inspiring to see the relationships that have been built between the members, staff workers, and Committee: people helping people, giving a hand up, not hand out. Thank you to George Handran and the Sidney R. Baer, Jr. Foundation for making it possible for these wonderful people to pursue their dreams.
I look forward to seeing everyone again in November and hearing your updates on your schooling and what’s next. Best of luck to those soon to begin their fall class/classes.
Mary Q. Pedersen Board of Directors, Fountain House
ALL ticket sales are now CLOSED! Please contact Susan Bell at 212.874.5457 with any inquiries.
The Associates Committee of Fountain House will host their sixth annual Fall Fête on Wednesday, November 6, 2013. This event serves to introduce a new audience of prominent young leaders to Fountain House’s comprehensive mental health model and its mission to fight the stigma associated with mental illness.
In the beginning of July, I was afforded the opportunity to travel to Lisbon, Portugal with Dr. Ralph Aquila and Alan Doyle, Fountain House’s Director of Education. The three of us, along with Dr. Juan Pedro Sapene of Argentina and Bertil Hartoch, a social psychiatric nurse from Holland, presented at the 21st World Congress of Social Psychiatry. The aim of our presentation was to share with mental health providers from all over the world the Fountain House model of recovery as it is now linked with integrative care and the Sidney Baer Jr. Center.
It was truly an amazing experience. I have never travelled very far from New York City. Everything was new for me: international airports, passports security screening, currency exchange, and simply being a foreigner in a European country. I believe that there is a lot of similarity between the states of anxiety and excitement; at times, I felt both.
Dr. Aquila and I flew out together from Newark airport on Sunday night June 29, 2013. We arrived in Lisbon on Sunday morning at around 10:00 AM. I can now sympathize with frequent travelers—jet lag is a really weird feeling. It’s like having a massive hangover minus the headache. Somehow, I managed to attend a couple of presentations by other participants on the same day that we arrived. What I learned was truly an eye opener for me.
What we do here at Fountain House is really cutting edge. It became obvious to me that mental health care in other countries, including “first world” nations, leaves much to be desired. Most mental health care providers still seem to be at a point of just trying to reach and provide basic psychiatric care to those in need within their respective populations; the critical issues of rehabilitation, recovery, integration, and healing into wholeness are barely addressed. It truly gave me a much deeper and profound appreciation towards our Fountain House community.
Our panel presented on Tuesday morning, July 2, 2013. We spoke at the University of Lisbon in a huge auditorium that seemed like it could seat 1000 people. I counted about 100 or so audience members. Each of us took turns and shared to the best of our ability various aspects of the Fountain House model. As everyone in our community knows, it’s hard to qualify and quantify exactly what occurs within our doors—so much is nuance here. What I tried to share was the fact that members here at Fountain House have the opportunity to define their own recovery as they discover and actualize their own innate talents. Consumers in many other countries are simply considered patients. The pursuit of self-realization and actualization is not even approached.
I have been a member of Fountain House for some time; I became a member in 1996. However, representing Fountain House members on this trip to Lisbon was a first for me. I learned so much about myself as a consumer in recovery, as well as the deep and genuine dedication our professional facilitators have toward us.