The Minnesota Mental Health Reform Crusade

Through the wonders of my trusty Google Search Bots, I was made aware of a book published by a regional university press. Upon linking to the press release for this book, I realized that in another less totally “connected” world in my past lifetime, I would have never known of this literary gem. This book, as fascinating and scholarly as it is, appealing to my personal historical interests and professional psychiatric mental health reform history, likely will have an undeserved narrow readership. But in my own literary zeal, I hope to support this author’s superb scholarship efforts in this field by calling attention to her wonderful book and read.

The book I am speaking of is “The Crusade for Forgotten Souls: Reforming Minnesota’s Mental Institutions, 1946-1954,” by Susan Bartlett Foote. This book is published by the University of Minne-     otaPress, Minneapolis, MN, 20108.

The Crusade for Forgotten Souls: Reforming Minnesota's Mental Institutions, 1946–1954

There exist dozens of books in print on the history of mental health reform, state hospitals, asylums, and so on. Additionally, there are many out of print books to be had by the student of mental health reform, thanks to the incredible networked of bookshops and sellers on the Internet. I have long been a student and collector (to my wife’s everlasting anti-hoarding tendencies) of antique and historical tomes on psychiatry, mental health, and psychoanalysis. In past decades when I first had my interest kindled in this scholarly effort by two mentors. These two far-sighted supervisors and teachers cultivated the awareness in me that many surprising answers and relevant insights could be gleaned from the acquaintance of the historical efforts of predecessors in our field and any area of human endeavor and understanding for that manner. To fuel my collecting and voracious reading appetite, I relied on one publishing and book reseller business in New York City (natch, where else?) as the only source for my dogged blood hound collector impulses. That business still exists, but sadly I utilized them far less often as their range of books seems narrow to me these days. But they still “cover” the field of psychiatric writers that I can find nowhere else so my loyalty to them persist.

This book serves as a scholarly, historical prod to this reader of mental health reform history because it is a unique book. It is not dry documentation of events as some books in this arena can be. Any area of historical review and retelling for a contemporary audience runs the high risk of taking the easy route of simply cataloging events. At least some of the history textbooks of my youth were such tediously boring examples.  Like many youths of that era, I could not understand why anyone would want to study history. What saved me was experiencing the teaching of history of other countries and cultures in schools overseas. I was awakened to the rich stories of the Middle East and of the British Empire in different schools. I returned to the US at the end of my high school years and dove into America political history in the only history course before university studies that hooked me. I focused on two area, the Civil War and the formation of the American system of government in the Revolutionary period. These interests prepared me for looking at my profession of psychiatry in a historical manner that afforded me a much deeper appreciation for even the most routine daily efforts in my work with patients and systems.

One of the first lessons that are highlighted in Ms. Foote’s book is the lost refrain that mental reform is not a new current of our time. Every generation of reformers seems to suffer initially from the realization that their efforts often have been duplicated in past eras. The helpful grace of this intellect and psyche warming circumstance is that any contemporaneous effort can be buttressed by learning from the directions of past efforts and their successes and failures.

Another lesson that is more sobering is that past reforms led to acclaimed successes that were much celebrated. Politicians, reformers, and those who implemented the changes bourne out of the results of the reforms felt early on that changes they had all worked so hard to accomplish would go a long way toward solving the problems that initiated the zeal of reform.

But the efforts did not lead to lasting change. In the state mental hospital orbits, reality overtook even the best of intentions.

Ms. Foote weaves a masterful story of a period of years in the pre-deinstitutionalization era, up to the early 1950’s. This makes for a truly engaging and fascinating read. Many different tides of motivations and ideologies are described. They range from social reformers of the 1800’s such as national figures like Dorothea Dix to a more intimate portrayal of local Minnesotan figures that were unknown to me. One of the other historical tributaries for the unique critical mass reached in Minnesota in the post-WWII years, was that of the singular religious community in the state, largely not existing elsewhere in this country except for the Quaker communities who pioneered mental health reform as early as the 1700’s.

One notable feature of Ms. Foote’s book helps stories of patients’ lives to come alive as few other books I have read. The second chapter has vignette life stories of several patients all ably researched from superb sources that the author read herself in unique local venues in Minnesota.

Only one other book I have seen rivals this book as far as an unusual source of person based history which I find to be the most interesting kind…That other  book with such storytelling power is “The Lives They Left Behind: Suitcases from a State Hospital Attic,” by writer by Darby Penney, psychiatrist-photographer Peter Stastny.

 This book resulted from the NY State mental health commission finding a treasure trove of patients’ suitcases after their admissions to one of the closed state hospitals. The authors wrote a book on the actual lives of the patients whose belongings they found. The authors found descendants living in venues in NY state and interviewed them learning more of their lives, filling in the details accordingly, making for an incredible read.
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USA’s Competency to Stand Trial Problem

A December 2017 article, entitled: “Colorado to spend $20 million to relieve ongoing backlog of mental competency evaluations; critics say problem was foreseeable,  in the Denver Post newspaper and recently reprised highlighted what has been a national crisis in the psychiatric inpatient care delivery system for at least the past decade.

Colorado’s problem has continued to balloon up so persistently that the article stated: “[the]State can’t keep up with monthly court orders for competency evaluation, which jumped from 146 to 215” swamping the entire state hospital bed capability. And as has happened in every other state, the regular emergent psychiatric admissions to the state’s public psychiatric hospitals were delayed, creating the all too familiar backups of patients in ERs statewide. And it must be remembered that almost all referrals for admission to state psychiatric hospitals are true emergencies.

A guard is reflected in a ...
Helen H. Davis, Denver Post file

A hallway at the Colorado Mental Health Institute at Pueblo, Denver Post file photo.

Judge Marsha Pechman of Washington state began fining Washington in the fall of 2017 $1500 daily after she found the state in contempt for not being able to deliver adequate care for the ITP patients. Her fines later escalated as she found the CEO of the Western State Hospital and the state mental health agency in contempt, to over $50M in total fines last year. By the time Judge Pechman began to levy the fines against Washington, its statewide monthly judicial orders, mirroring Colorado’s almost exactly were averaging 291 in-jail evaluation orders.
The issue is that most states in the USA continue to be flooded with mandated admissions of inmates from state judicial systems for psychiatric evaluations. These types of admissions are variously termed ITPs or incompetent to proceed to trial patients and other arcane terms derived from states’ laws designations. Washington state has struggled mightily more than most states with this issue so much that a Washington state judge has fined the state over $50M in the past two years because of the delays in care for other patients who had ended up warehoused for weeks to months at a time in general hospitals all over the state.
The Governor of Washington, Jay Inslee, who has been working at a furious pace with the Washington state legislature, recently announced new plans to try to have regional, non-state hospital-based forensic evaluation centers in different parts of the state by 2022 to handle all the ITP case needs. This is innovative in that most states do not have such a system.
In decades past, states had “forensic centers” that were designated the proper facilities to handle such cases. In the states that had such, their capacities were usually not increased from levels of the 1960’s. One such notable and nationally recognized center was and still is Michigan’s Center for Forensic Psychiatry south of Ann Arbor Michigan. Another has been the infamous Massachusetts facility Bridgewater state hospital’s forensic unit. Its heyday has long passed, and it has been the site of repeated scandals for a good decade and is not such a good example…
Nationally some of the forensic facilities were phased out as such units were incorporated into state psychiatric hospitals’ physical plants. But overall, the bed needs were not increased to keep up with population growth for over 50 years, hence the ‘sudden’ swamping of these facilities in whatever form they existed nationally.
Additionally, the impetus of the legal system has been to increasingly become scrupulous about ensuring inmates’ rights are protected to assure access to mental health evaluation and treatment. Issues of below average intelligence, organic mental conditions and medical conditions affecting legal issues such as the ability to know right from wrong, judgment, impairment of any sort at the times of commission of crimes, were more readily identified than ever in the past.
Also, it likely has become the standard of practice in the world of legal defense representation, to adequately refer to such psychiatric review whenever there is a question such an issue may exist with any defendant.
All these factors have fed into the current national crisis of explosion of need for such forensic psychiatric services at all levels and not just in infamous trials involving serial killers or cases involving the rich and famous.
All states who currently fall short of providing these mandated services will have to face the coming necessities of funding for such services along with all the other inadequacies of social, educational and human services gutted over the last 30 years. How all this will play out will in no small part shape the political and social policy debates in this country for decades.

Radical De-institutionalization History in Italy

In my journey through my training centers becoming a psychiatrist, I was accidentally graced that my medical school and subsequent residency centers had medical libraries with superb historical collections. There are a number of other medical school libraries who have similar collections. At Michigan and then at Duke, I found myself spending empty hours reading histories of medicine and then psychiatry in the rarefied collections rooms. These left an indelible mark in my reading appetites that have lasted my entire professional life.

The past five decades of exposure and experience have faced me with the enormous shifts in practice models, the wrenching changes in mental health service delivery since the 1950’s, and continuing dilemmas posed by seductive national solutions that brought with them worsening problems. The overall shift in western mental health care has swung from outpatient care for the well-off seen by private practitioners, the subsequent mental health center movement for the general populace from the 1960’s through the 1980’s, and the even larger but mostly unseen segment of public inpatient psychiatric hospital care that dwarfed all other portions of the mental health care pie. This last “market” underwent the most severe changes of all. By the latter 1960’s the movement to close state psychiatric hospitals was underway fueled by the new sociologic analyses of authors like Erving Goffman and the emergence national awareness of the wretched, medieval conditions of state hospitals and wretched treatment of patients. Commitment laws came to be humanized with respect for patients’ rights to legal representation after the 1974 Supreme Court Wyatt vs. Stickney decision. De-institutionalization, the discharging of inpatients from state hospitals proceeded through the 1990’s, eventually emptying states’ psychiatric hospitals of roughly 4/5 of their beds, closing old hospitals in wholesale fashion.

Many figures played major roles in this profoundly important movement. R. D. Laing in the UK tried treating schizophrenic patients in more open, experimental settings. Typical of those times, whether in state hospitals or a number of private free-standing hospitals, patient governments were formed. Patients were encouraged and helped to make many personal and treatment decisions for themselves. The “therapeutic community” movement arose out of, and in parallel, grew from this non-authoritarian, more democratic hospital life. Hospitals were opened up to the community. Echoing rehabilitation practices of nearly a century before, patients were permitted to work and earn money. Social activities were begun with the return of art, dance, crafts, and musical pursuits.

One very influential source of the de-institutionalization movement in psychiatric hospital care came from Italy in the 1960’s. This piece of psychiatric history is little known in the USA.

The Italian psychiatrist who pioneered many of the components of radical change in public psychiatric hospitals was Dr. Franco Basaglia. His story is nothing short of fascinating. As is so often the case in the culture of Italian figures no matter what their field of endeavor, his crusade began to take shape in his younger years being exposed to different mass political movements and periods of social upheaval in Italy. He was born into the fascist periods of Italy before and through World War II. He absorbed radical social concepts from the communist and socialist movements of post-war Italy. These concepts guided him to become the effective psychiatric reformer that led to his national fame and regard. This kind of personal development would be viewed as heretical, treasonous and would prevent any achievement in this conservative America. But in Italy, Basaglia’s social-intellectual development made perfect sense.

Basaglia did all the things we think of radical in a wretched state hospital. He empowered patients, tore down fences, did away with tortuous physical treatment, had patients go into the community and so on. He did all this in a true backwater town on the northern border away from any and all big cities and centers of thought and social change. He worked for several years in isolation and obscurity. Then through a fascinating chain of fortuitous events, his efforts began to be noticed and the powerful beacons of the press and celebrity status quickly enveloped him, his work and his staff.

His efforts came quickly to be acclaimed and trumpeted nationally and internationally. His influence in Italy was far beyond that of any of America’s famous reformers such as Dorothea Dix, Nelly Bly, Erving Goffman, Laing and all the others. Italy responded with the national social change that has only been equaled in the Scandinavian countries, not France, nor the UK and especially not in the United States.

With a few years, a reform law was passed in Italy named after Basaglia. It set the national goal of the closure of ALL the public state psychiatric hospitals!

This was indeed fully accomplished, a feat that is beyond astounding in the annals of national social change. For several decades now in Italy, there have been no mass hospitalizations of the chronically mentally ill. There do not seem to be hundreds of thousands of “CMI” (chronically mentally ill) persons everywhere on the streets of Italy. Somehow Italy with all its frequent political crises, changes in governments, scandals, raucous politics and all the other tumult that seems par for the national life of Italy, has done what other western societies cannot care pretty well for the nation’s mentally ill.

I would refer the reader who might be interested in the history of Dr. Franco Basaglia and the “reformation” of Italy’s national mental health de-institutionalization and revolution to the writings of Prof. John Foot of the University of Bristol in England. His book, The Man Who Closed the Asylums: Franco Basaglia and the Revolution in Mental Health Care  is well worth the read. An online article published in VERSO, “Closing the Asylums,” gives readers a worthy overview into Dr. Basaglia, the times and his accomplishments.

Realizing what Basaglia accomplished forty years ago leaves this student of psychiatry, its history, and observer of our current national crises, sad for where we have been trapped by our own hobbling prejudices, resistance to social change and pattern of quickie formulas that led to the all too familiar conundrum of “unintended consequences,” and bigger and more complex messes with each year in mental health care delivery.

New Psych Beds Still Needed Nationwide; Two Differing Solutions

A somewhat new trend has been emerging over the last 1-2 years and is becoming more of a force in mental health reform.  That trend is the efforts of private and state-private psychiatric care systems to try to preserve and add psychiatric inpatient beds in their areas. The efforts testify to the need for more psych inpatient beds almost everywhere. They are also confirmation of the huge national mistake that has been made in the previous 40 years or so nationally to close inpatient state hospital psychiatric beds.

I will first set the stage, reviewing some of the factors leading to a national inpatient bed shortage. Second, I will discuss two recent differing state systems’ efforts to add or preserve inpatient psychiatric services. One is a novel success story that bears study, and the other is a looming failure that illustrates some of the factors that persist that impede this kind of mental health care system delivery. Lastly, I will conclude this lengthy piece, reviewing why the national loss of inpatient beds happened, contrasting what occurred in the public arena, which is so well known, with what happened in the private psychiatric treatment bed world. Continue reading “New Psych Beds Still Needed Nationwide; Two Differing Solutions”

Infrastructure for People Matters Also

At times I like and choose to highlight short advocacy pieces that are opinion pieces written regionally that are so eloquent I feel they are worth sharing. They also serve as crystal clear reminders that mental health reform issues are really quite universal in our country.

One such piece was just published in The Buffalo News just today, August 30, 2017, still during the continuing agonizing events of Hurricane Harvey down in Houston Texas. This is a Wednesday as I write this and it has been raining in the Houston now for 5=6 days straight with over 50 inches all told having fallen in many areas, covering now up to 50 counties. It is dawning upon all of us, and without a doubt that domestically this may be not only one of the “defining issues” of the Trump Presidency but likely one of the “dominating” social issues of his tenure. The initial help efforts have been monumentally large, fast in onset and heartening to all who witness the “citizen” led and self-initiated efforts portrayed on the news outlets.

The infrastructure costs and time to repair will be higher than anything this nation has ever seen and will clearly take years. This is an incredibly sobering realization for this country which is many ways been spared because of its temperate climate the magnitude of many natural disasters that seem to inflict cruel pain and hardship on poorer regions of the world such as Bangladesh’s almost annual massive floods, displacing up to a million people during its monsoon season. I mention this because it is also happening there this very week also.

But there is another thread that I wish to emphasize in this post as no doubt many other citizen writers/bloggers and most of the national media will discuss and likely also argue over for a few weeks. That is the national physical infrastructure that has been neglected and minimally maintained in most parts of the country for a number of years if not decades. Urban plumbing, water systems, waste treatment capabilities and plants, water resources, roads, highways, airports, and bridges have come to be on the minds of governments at local, state and national levels.

Continue reading “Infrastructure for People Matters Also”

Drug Free Inpatient Psychiatric Care in Norway

Asgard Psychiatric Hospital, Tromso, Norway, credit “Mad in America” blog, March 2017 [http://bit.ly/2wbRrJW]
In my previous post I ended up writing an overview of the changes over the time of the last 24 years since I personally date “mental health reform” commencing in this country as being the year 1992 when news of the beginning sweeping changes (at first budgetary adjustments due to the falling state’s revenues during the implosion of the Big Three Automakers) that surfaced in Michigan under then Governor John Engler. In short the progression went something (very approximately) like this: cutting of mental health budgets, closing of public inpatient psychiatric beds (downsizing of out of date, out of code, aged state hospital relics), closure of multiple facilities, conversion of the “county mental health center” based system of care delivery from the 1963 JFK Comprehensive Mental Health Center Act (that name is from memory and may not be completely correct) to regional agencies that covered larger areas and population groups, conversion from combined state and county funding to various forms of block grant funding still heavily reliant upon federal Medicaid funding (this is ‘mucho importante’–as my Texican father would say for emphasis–and must NOT be forgotten as it is still pivotal today), to beginning versions of degrees of privatization of these regional mental health care delivery agencies, opening outpatient mental health services to entrepreneurial provider-business groups who were somewhat free to pick and choose what types of services they wished to deliver and which they wished to avoid and not pick up.
In the early phases of this general blueprint of national mental health reform, as it came to assume the stature of as more states adopted this governmental approach, there was much optimism that fueled understandably this effort. Many different groups seemed to be more involved than ever before, including private enterprise, a novelty in and of itself. The boundaries between private mental health care centered previously in private free standing psychiatric hospitals and units in private community or university medical centers and the world of private office psychiatry, and (whew), the worlds of public mental health centers and state psychiatric hospitals began to blur especially on the outpatient side of things. Hospitals bought psychiatric practices as they had been doing with medical practices. Small private psychiatric groups either had to greatly expand numbers of sorts of practitioners and services (more non-MD staff and services) and expand patient volume, or be absorbed by hospitals that had gobs of capital and could assume and handle the higher and higher costs of overhead (billing especially which became a nightmare in the late 1980’s), or close. There seemed to be at least in my part of the world a phase of retirement by choice of more than the usual attrition-retirement rate of private psychiatrists. I recall a medium small city of less than 100,000 in which all three private/public child psychiatrists other than myself left practice and the area in the mid 2000’s as the enormous forces of the change washed over the practice world. A number of practitioners affiliated with highly capitalized hospital groups and survived in that manner. Others simply moved lock stock and barrel in more affluent metropolitan areas with strong economies and higher standards of living to a cash only, no insurance practice model that had long existed especially in affluent cities with large university medical schools and departments of psychiatry that quietly influenced their training program graduates to stay in those areas and practice the solo cash only model since the 1960’s or so.
Now I think we are in the post revolution phase. Many models are in use, many are finally getting stable footing, strengths are being recognized and resources more appropriately developed and mobilized (mobile crisis intervention and outreach ACT teams). Similarly on a not so good, no reason for victory dances yet, side of things that deficits are now more glaring than ever. Inpatient services have contracted dramatically everywhere. Private psychiatric hospitals closed or were converted to other uses, some nationally sized private psychiatric hospital chains closed dramatically in the very early 2000’s as once abundant insurance reimbursements (at least a fair to a hefty portion of such poorly managed and spent causing 20 years of a “private psychiatric hospital bubble” to implode. Inpatient beds decreased in this country for mental health treatment decreased perhaps by as much as half which is mind bending if one ponders that as the population was still growing, drug abuse was increasing exponentially. Even the VA Hospital system was not prepared as seen in its inability to handle and furnish adequate services for several years after Desert Storm (brief as it was) and especially after the War on Terror began in earnest in 2003 with Iraq. The VA Hospital went through its own version of excruciating upheaval as it had to “reform” its mental health services, head rolled, appointment scheduling scandals erupted (please recall the Phoenix Indian School Road VA Hospital mess ten years ago).
The streets, ERs, and jails became the new “receiving units” for the chronically and acutely mentally ill, the trans-institutionalization consequence of the above shrinkage of the existing5130-year-old mental health infrastructure. This has been and is still being more than adequately covered in local, regional and national media of all types and I will not further belabor here.
I would like to direct our attention to one new and not so new treatment model that is making a comeback in the midst of all this controlled change and “disruption” of existing models (Internet speak), or paradigm shift of the philosopher Clifford Kuhn. That is inpatient psychiatric treatment without psychiatric medications.
At the top of this post is a picture of a psychiatric hospital Asgard, in Trosmo, Norway (I must confess I am totally unschooled in the existence of either before I found this blog post article). This hospital is as the article/post details 215 miles north of the Arctic Circle. I have lived for some months on three occasions in my youth following my peregrinating international rambling mining engineering father to his contracted job sites that were snowy cold climates but none of them would compare at all to what I imagine the clime of this location.

The means by which I came upon this article entitled, “The Door To A Revolution in Psychiatry Opens,” is worth detailing. The author of the blog post is Robert Whitaker, a journalist and author of two books about the history of psychiatry, one of which I have and have read with great enjoyment, fascination and a good for the soul dose of humility, Mad In American: Bad Science, Bad Medicine, And The Enduring Mistreatment Of The Mentally Ill [click link for Amazon review etc.]. Mr. Whitaker is in the foe of psychiatry camp along with perhaps better known anti-psychiatry physician Peter Breggin MD. Mr. Whitaker’s book focuses on the failings and disasters, failed theories, bad side effects of many psychiatric medicines and so on. In all fairness I follow him with searchbots on the Net and this turned up. If you loathe all things psychiatric, then this is one of the books for you in truth. Form my point of view it is a needed viewpoint and one to help us in the guild…though I do not think of myself as all that nefarious and evil, and talented writers such as he are to be commended and accepted for their necessary work.

So why is this seeming sidebar important in this post? Mr. Whitaker is a founder of the aforementioned blog, Mad In America and his perspective and where he starts from is reflected in the blog and his book. And the article in the blog that one of my trusty bots found which is referenced for the intrepid reader above, is about the manifestation and another test and trial of medication free treatment. This is being conducted by well meaning and very well trained professionals. From the blog’s post which is very lengthy (even moreso than my usual oververbal posts) details the enormous and creditable preparation that has gone into this movement in Norway. This is no heretical nut job splinter movement. The government of Norway is mandating the trials of this mode of inpatient treatment which is apparently being, or gong to be tried in other psychiatric hospitals as well. The post makes for absolutely fascinating reading.
In the United States we have had a few experiences with such models in this general realm. A few exclusive (I guess that would be an appropriate word to apply to hospitals for the wealthy and famous) psychiatric hospitals tried this approach on small scales in those heady days of the 1960’s and 1970’s when some might say a bit derogatorially, “anything went.” Most of the practice groups were spearheaded or led by charismatic psychiatrists operating within a small clique or group with similar beliefs. In Great Britain the most well known, at least in hippie and college circles in those years was Ronald Laing who treated psychotic patients with little or no medicine, small patient units, and great amounts of time spent in individual and group therapies. Dr. Laing wrote a number of books over a span of almost 2 decades but his book, The Divided Self, is what put him on the map internationally. Almost every student in psychology in the colleges of those two decades of the 60’s and 70’s read this book. Laing came to be a highly sought after speaker at least on the slightly or very avantgarde college circuit. I myself heard him speak twice. Outside of a minority of devotees in international psychiatry, he was viewed as mostly a charismatic oddity and very much as a product of what was going on those days and years. The only fairly well regarded psychiatric researcher practitioner who practiced in an arena that could be regarded as in the camp of psychiatric treatment without medication was Sir Humphrey Osmond also of the same time period. He was more mainstream and a clinical researcher. His departure from the mainstream or whatever one wants to calls the ?silent majority? of psychiatrists was marked by his openly peer reviewed and published trials of hallucinogenics, mainly LSD in the treatment of psychiatric issues ranging from psychoses to the terminally ill. Most if not all his data was anecdotal, case reports of fantastic religious like euphoric life changing experiences of LSD for patients. The response to his work was underwhelming, to say the least in all fairness. In those times of the experimentation with LSD, DMT and the other designer hallucinogenics, many of us standard, perhaps stuffed shirt psychiatrists did not see these wonderful results. All I remember as a green medical student and then a green psychiatric resident was handling people in great psychiatric distress, having hours and hours of terrifying LSD induced experiences that were unnerving to witness and work with and for a while hard to treat. So the rest of us had a different view of the hallucinogenics. The use of ‘natural’ hallucinogens such as psilocybin in Native American cultures is different for the most part and I will not address that here as it is altogether different.
In spite of my huge built in bias and years of standard experiences in the current world of psychiatric treatment, I want to see what the Norway efforts and experimental treatment models can accomplish, what they evolve into, what factors they may be able to tease out since we no longer have too many sponsored or approved studies along these lines going on in the western world of medicine. I can predict that almost all “IRBs, “Institutional Review Boards” of clinical psychiatric research centers would almost never give approval to such work. More the pity as perhaps there are still interpersonal and talking therapy approaches that work better than others with standard inpatients and it might be possible to see those stand out in relief without medicines in some patients. I am more than willing to give the Norwegian effort a go at things and am personally glad that it is possible. I hope that it is studied “up one side and down the other,” that as much data as possible is gathered and presented to the world of treatment practitioners for all to review.
Lastly, I must comment on the other rare element contained in this article, all my own past bias coloring experiences aside.
This article goes to great and eloquent lengths to trace the history of various politico-social movements that have grown in Norway, and to at least comparable extent in the most of the other Scandinavian countries, of the right of what I would call a different form of self-choice, self-determination that almost has little or no parallel in our social views, spoken and unspoken mores and standards. The narrative of the author is marvelously woven drawing upon years of social thinking in Norway, exemplified by various social thinkers, commentators, critics, leaders of a number of “citizen advocacy” groups as I would term them. The author successfully brings the reader to a depth of historical feel and appreciation for how all this has developed in Norway so that even if you are not an instant convert, you can very much appreciate this psychiatric treatment model’s origins and roots. For this reason alone, this blog post is well worth the read.

Healthcare Costs: The Perpetual But Evolving Seesaw

It is no news at all to anyone reading this or anything else at all in the media for the last couple of decades that in the United States, we have the costliest health care services in the world and that we do not get our full “bang for our [many] bucks” in the cost equation. Yet as far ago as the 1970’s the world’s wealthiest groups in the world came to our hospitals and big name healthcare clinics for the “top healthcare.” I recall then when certain families of a certain “royal” family born of petroleum revenues and riches came to my training, teaching and later, practice affiliated hospital for all sorts of medical and very secret psychiatric care. Those folks always created a great stir in the entire hospital system. They usually took over at least an entire wing of a floor of the hospital and had instituted all their dietary restrictions, religious requirements, and at times brought some of their own staff; contrary to the usual undertone of some prejudice, their trappings and accouterment of their societal practices actually made things easier. But the greatest stir was always when they left the hospital to return home at the end of the treatment stay for whoever the patient(s) was or were. These folks would bestow expensive “trinkets” upon the hospital staff they had liked and favored. The gifts were in the league of Rolex watches and whatever was in vogue at the time but included eye-popping jewelry, expensive Italian shotguns and on and on. Cost of the medical care was of course no impediment for these folks and their new contemporaries in the decades since, in the rapid incubating industries of high fashion, investment, mergers and acquisitions, international banking (and who knows, maybe even money laundering), drug lords under assumed identities (usually in highly securable and ‘safe’ free standing clinics instead of rambling hospitals with as many security holes in them as one one of my old sweaters. This phenomenon of perhaps ostentatious consumerism of costly healthcare is one of the weird epiphenomena of our healthcare ‘industry’ that illustrates its almost bizarre contradictions. And it occurs in all the big name medical institutions in the countries in the northeast, south, midwest, far southwest, upper far west; you name a region with big world beating specialty medical care in one or more disease and you will find from time to time, the world’s supremely wealthy beating a path to their door.

Some countries have taken difference copycat or “opposite-cat” approaches to this medical social snobbism of extreme consumerism. India and Thailand have in the last few years gotten into or started the cheaper markets for elective surgeries especially for fractions of the costs of standard American healthcare institutions. There does not seem to be too much wrenching of scrub scrubs suits, self-flagellation with IV lines by surgeons decrying this development but it is going to be interesting if this development starts to significantly cut into the receivables of lots of hospitals.”Oh, I had my gall bladder done in the Punjab, I had a great time, and save $9,000 too!” Which is to say we still do not have true competition in this country. Any of you free marketeers listening out there? All we have is siloed, protected from almost any similar medical business, sectors, having no overarching economic influences that touch more than one sector and therefore the Great God of Free Market Competition that has for 30 years been supposed to have controlled prices. What we have are ‘cooperative co-monopolies.’

Let us review for a few lines what we have tried.

Continue reading “Healthcare Costs: The Perpetual But Evolving Seesaw”