Over the years I’ve grown more and more frustrated when viewing the mental healthcare system of which I am a part, as I consistently see this system fail to adequately meet the needs of various segments of the population. I have watched as the LGBT community, women, blacks, immigrants, children, and so many others – often the most disenfranchised among us – have been ignored, underserved, and even at times outright discriminated against. And not just by ignorant or otherwise unqualified clinicians. In fact, sometimes problematic diagnoses and treatments have been officially sanctioned, as was the case with the APA’s erstwhile designations of homosexuality as a mental illness and alcoholism as a personality disorder. Even now, if you’re not a well-to-do straight white male, you’re probably drawing the psychiatric short straw.
Recently I’ve been thinking quite a lot about this issue, especially as it relates to women. It seems to me that in the mental health community women have historically been ignored, under-researched, improperly diagnosed, and poorly treated. The main problem as I see it (aside from the outright misogynistic discrimination of certain researchers and clinicians) is that for decades therapists have treated women using methodologies developed by men, for men. And in case the psychiatric powers that be haven’t noticed, women are most definitely not men. This homogenous approach to psychiatric care persists despite the facts that male and female bodies and brains are structured differently, men and women are raised with different cultural rules and expectations, and men and women usually face vastly different life challenges. Given this, it seems to me that diagnosing and treating women using current criteria and methodologies is at best likely to be less that 100% effective. Unfortunately, despite the vociferous efforts of feminist clinicians since the early 1970s, this clinical bias is more systemic than isolated.
Of course, it’s not just women who are underserved. Practically anyone forced to seek mental health care in a public facility (usually for financial reasons) is getting far less than the best we can provide. For instance, in most public hospitals and the VA, interns and residents comprise the bulk of the clinical staff. Yes, these folks are hard-working and talented, but they often lack the expertise that time, experience, and ongoing training can provide. Plus, multidimensional treatments inclusive of experiential, bodywork, and mindfulness therapies are non-starters in the public sector, even though they’ve generally proven effective in high-end, private sector treatment settings.
The simple, unvarnished truth is we closed our sanitariums and state-run psychiatric hospitals in the mid-twentieth century. We were promised these facilities would be replaced by the widespread implementation of step-down, community based care centers providing home-based, “return to real-life” programming. That never happened. Instead, we got more prisons, and that is where the bulk of this troubled population is now housed, especially when those individuals are poor and/or a minority. And even when a person with psychiatric issues does make it into one of the painfully few public facilities that remains, the average stay is only about a week, hardly enough time to do anything more than stabilize a person in crisis (and people don’t get admitted for anything less than a very serious crisis) and put them on some psych meds. Oftentimes patients are pushed out the door before their issues are even properly identified, making follow-up care elsewhere incredibly difficult.
The Double Whammy
It’s no secret that addiction and other psychiatric diagnoses often travel hand in hand. I see this almost constantly in my work. Mental illness feeds the addiction; the addiction feeds the mental illness; and so on. It’s a vicious cycle, and it inevitably spirals downward, exacerbating the life issues that already exist. Unfortunately, very few treatment facilities fully recognize the (relatively common) interrelatedness of mental illness and addiction – especially the relationship between early-life trauma and adult addictions. Our field is just beginning to assess for and treat these issues in concert, and, once again, this level of care is usually only available to those who can afford the multidimensional, multidisciplinary, non “medication-as-the primary-solution” focused treatment found in high-end private facilities. Elsewhere, substance abuse centers typically assume that getting and keeping a client sober will eliminate any underlying mental health issue. In similar fashion, mental health facilities usually assume that treating trauma, depression, or another primary diagnosis will cause a patient’s long-standing problems with addiction to simply wane and disappear. Unsurprisingly, patients treated in this fashion rarely achieve any sort of lasting, meaningful recovery either interpersonally or in their addiction.
Unfortunately, as mentioned above, there are relatively few mental health or addiction treatment centers that focus on the diagnosis and treatment of both serious psychiatric disorders and addiction, more commonly known as comorbidity. Thus, thanks to the shortcomings of the mental health system, a lot of people end up being treated for only half (or less) of what should actually be addressed. This is not a good approach, and it needs to change.
As I’ve written in a previous blog, men and women, particularly when we’re dealing with addiction and/or trauma, typically present with dissimilar attitudes and issues, and they typically respond very differently to commonly used treatment modalities. For instance – and please understand that I am generalizing here – women are much more willing to enter therapy, and they do so with more enthusiasm and less trepidation. They stay longer in treatment, they are more willing to discuss traumatic and/or embarrassing issues, and they adapt more readily to the social aspects of certain treatment settings such as group therapy, inpatient treatment, and outside support groups. However, many women, especially early in the healing process, will struggle with linear, directive forms of therapy such as cognitive behavioral therapy. (Men typically prefer those forms.) Rather than taking direction or completing assignments, women will openly question the need for direction, sometimes to the point where the therapeutic relationship simply breaks down. So even in substance abuse rehabs, where directive methodologies are, generally speaking, by far the most effective methodology, clinicians must be willing to tailor their approach. Simply put, gender is not considered enough in the treatment of mental health issues and addiction. Again, this is not a good approach, and it needs to change.
So What Do We Do?
The truth of the matter is every client is different, and nobody – male, female, rich, poor, black, white, or whatever – ever fits neatly into any clinical model, diagnosis, or treatment modality. Age, race, cultural issues, and many other factors influence every client and situation. As such, therapists must always pay close attention to a client’s reactions, seeing what that individual is (and is not) tolerating emotionally. Pushing too hard with any approach, even the approach that is supposed to work, can be counterproductive. This need for wariness increases when dealing with historically underserved populations. Perhaps over time women, ethnic minorities, the LGBT community, the poor, and other marginalized groups will be properly researched, with specific diagnoses and treatment modalities developed for them. Until then, it is up to the clinical community to take things on a case-by-case basis, working hard to find the best diagnoses and methodologies for each individual client, taking into account all factors that play into that person’s life and issues.
Robert Weiss LCSW, CSAT-S is Senior Vice President of Clinical Development with Elements Behavioral Health. A licensed UCLA MSW graduate and personal trainee of Dr. Patrick Carnes, he has developed clinical programs for The Ranch in Nunnelly, Tennessee, Promises Treatment Centers in Malibu, and The Sexual Recovery Institute in Los Angeles. Mr. Weiss has also provided clinical multi-addiction training and behavioral health program development for the US military and numerous other treatment centers throughout the United States, Europe, and Asia.
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Last reviewed: 18 Sep 2013