Bernadette Grosjean on "From Locked in to Locked Out"
On the future of mental health
Posted May 2, 2016
The following interview is part of a “future of mental health” interview series that will be running for 100+ days. This series presents different points of view about what helps a person in distress. I’ve aimed to be ecumenical and included many points of view different from my own. I hope you enjoy it. As with every service and resource in the mental health field, please do your due diligence. If you’d like to learn more about these philosophies, services, and organizations mentioned, follow the links provided.
Interview with Bernadette Grosjean
EM: Can you tell us a little bit about the work you do?
BJ: I was trained as an MD and a psychiatrist (both in Belgium and the US) and was trained in both psychodynamic and cognitive therapy. I am a firm believer in teamwork and interdisciplinary collaboration in the spirit of what has been called “bio-psycho-social model.” I do not, however, like that name, which, poorly interpreted, can encourage the fragmentation of care. I favor a holistic model where we look at the entire patient/client history, emotions, physiology (including diet, exercise), and her or his environment, family, work (or lack there of), housing (or lack there of), social support (or lack there of) etc.
I worked for 12 years in Belgium, half the time in an inpatient unit and half in private practice. I moved to Los Angeles in 2000 and have since worked in one of its County hospitals with people who mostly have no insurance. I have worked on the inpatient and outpatient services, in a crowded emergency room, and, for five years, in a “field based” program, “field” being the street, jail, board and care, private house. I tried to engage and help “patients” that our traditional system could not keep in treatment.
This approach can help prevent them from falling into homelessness, or into jail or into the “revolving doors” of our remaining psychiatric hospitals. For the last two years I also have a small private practice in Los Angeles where, in order to have the time and freedom to offer the quality of care I want, I do not deal with any insurance system. One of my specialties is Borderline Personality Disorder but of course over my 30 years of practice I have worked with sufferers of differing torments–psychoses, depression, addiction and trauma.
EM: You’ve written a long essay called “Rethinking Psychiatry: From Locked in to Locked Out.” Can you tell us a little bit about its intentions and findings?
BG: My need to write the essay stemmed from a combination of sadness and indignation vis à vis the current state of care and access to care for patients with psychological/psychiatric problems.
In the USA, hundreds of thousands of people suffering from multiple and severe psychiatric problems such as schizophrenia, bipolar disorder, trauma and substance dependence, are either homeless or in jail, and unable to get proper care. The emergency rooms of public hospitals are overcrowded and have almost no place where to send the mentally ill for treatment. The staff is often physically and emotionally injured by a returning flow of patients for which they have little to offer because there are no places to send them to be healed. How could this happen in 2016 in the USA when billions of dollars are used to pay supposedly efficient medications and “evidence based” therapy?
I wanted to denounce a greedy system and the danger of having medical professionals receive a good part of their information and training via the pharmaceutical industry. For over twenty years, pharmacotherapy has been inappropriately presented as the only efficacious and necessary treatment. This has a devastating effect on other kinds of care, which are barely paid for, such as psychotherapy and long-term in-patient care.
I wanted to denounce the transformation of medicine into a for-profit industry that has turned healthcare professionals into a type of factory worker, doing repetitive, hurried and mindless work–exactly the opposite of what it should be (unique, detailed and soulful.)
However, I also wanted to caution not to thrust aside medications totally, as society did with the old psychiatric hospitals, when it accused them of being not only useless but responsible for myriad problems including the existence of mental illness itself. Remember what happened in the 1980’s– some believed that psychiatry and internment were the sole cause of mental illness and others did not want to pay for care. The result is that during thirty years, 450,000 inpatient beds were closed. Soon US jails and streets were filled with a very similar number of people–still suffering, still unable to care for themselves and now left either abandoned, without hope, or locked up.
EM: What would you like to see change in the mental health landscape?
BG: My choice of becoming a physician and then a psychiatrist had more to do with a calling (vocation) than having a job (profession). During the last 30 years, the systems in which care is given have grown more and more estranged from their initial task (human caring and healing) to a new one: “making money.” In this indecent game, the aim for the insurers has (apparently) become how not to pay providers (asking caregivers to comply with an ever expanding list of documentation requirements and denying payment based on that paperwork).
On the other hand, the goal for many Health Care Institutions and their shareholders is to bring in as much money as possible. Clinicians working for these institutions are continuously asked to increase their (financial) productivity either by multiplying the number of “technical things done” or by increasing the number of customers who come for the highest paid sessions (i.e. medication checks as opposed to psychotherapy visits). In this “money game” paperwork and redundant quality control systems are what protects the system. What brings the money in is what is written, more than what is done. In that context, the time spent with patients is the only thing that can be reduced without (short term) direct consequence for the organization.
In a new landscape …
I would love for clinicians to be given again the ability to decide how much time they need to work properly with each patient and how often they need to see them. I would love for the patient to be able to see the same practitioner during the treatment and not have to meet and rediscover a new person every three months. We need time to practice a comprehensive, thoughtful psychiatry not a reductionist triaged one. We need the time to engage people, to build trust, to heal. It takes months of repetition for our plastic brains to change and incorporate what was learned in psychotherapy. It is just a biological fact. We need time for the silence when tears are all that is said, and the quiet open space during which a crucial memory can finally arise.
There needs to be time for psychiatrists to be able to provide during the same session both psychotherapy and pharmacotherapy, which has been recognized as the most efficacious way to treat most psychiatric problems. Finally, I would love for practioners to be able to work for Systems that let them use the essential parts of their mental energy and their extensive training to treat people, not to get lost in endless coding tasks.
EM: What are your thoughts on the current, dominant paradigm of diagnosing and treating mental disorders and the use of so-called psychiatric medication to treat mental disorders in children, teens and adults?
BG: The birth of that paradigm, and the end of clinical psychiatry as an interpersonal sophisticated healing Art (and an Hippocratic discipline) was precipitated by two factors: first, the myth of “chemical imbalance,” embraced vigorously by mental health professionals in the last twenty years, and second, the submission of an entire professions to a new Bible–the DSM (Diagnostic and Statistical Manual of Mental Disorders).
Both phenomena have contributed to a deceitful reductionism, an impoverishment of the art of psychiatry and an alarming inflation in the number of diagnoses and in the number of people diagnosed with some kind of “disorder.” As a consequence, we have witnessed an absurd and dangerous increase in the prescription of powerful psychotropic medications that were in the past reserved for a few very specific and debilitating symptoms. Last, but not least, these medications, usually reserved for an adult population, are now given with the same dangerous enthusiasm to elders, teenagers, children, and even toddlers (RIP Rebecca Riley.)
The myth of a “chemical imbalance” was presented as the model to explain and treat mental illness. The idea was that mental illness was a consequence of a lack of balance of certain molecules in the brain and that this “imbalance” would be corrected by taking a medication. The patient no longer feels shame–his other problem (depression, delusion, anxiety) is “biological.” The psychiatrist becomes a psycho-pharmacologist and the pill has become the cure.
When the complexity of the human mind is reduced to the ups and downs of a limited number of molecules, we no longer need the psychoanalytic couch nor play therapy or lengthy explorations of the past and its traumas. Who would reject a quick fix for all? The practice of overvaluing the power of medication may have started in good faith and with the enthusiasm created by a possible cure for devastating diseases. However the ten-minute medication visit has now become an almost universal practice because many physicians no longer have the time, the training or the financial possibility to choose to do anything else.
What I call the myth produced by the DSM is the fantasy that a document, initially created to organize observations, could become “The knowledge-about-everything-psychiatric-that-is-observed-in-human-beings.” The DSM was initially conceived to organize and identify mental disorders and provide mental health professionals with a common diagnostic language. The problem arose when the tool was promoted to Bible status and used to teach psychiatry to younger generations of physicians. With time, the successive editions, written by researchers, some influenced by the pharmaceutical lobby and academic interests, created an exponential number of “disorders.” As a consequence of the DSM’s over-inflation, we witnessed the categorization of casual human emotion into some sort of pathological ailment requiring medication. “Feeling sad” after the loss of a love one is a good example. It can now be a disorder.
The DSM’s criteria and categories are also used to determine which pill should be given for which “disorder” and how much money insurance will pay for the treatment of that disorder. Good-bye uncertainty, doubt, failure. “Follow the guidelines” and everything will be fine. Of course, it does not work that way. Bookshelves will never replace books and human complexity cannot be subsumed in a few codes and definitions.
A classical example is the one of patients suffering from borderline personality disorder (BPD), incorrectly labeled “Bipolar” in part because the hospital gets paid much more for a “Bipolar Diagnosis” than for a BPD disorder. In a sometimes deadly Kafkaesque logic, the patient may be then given medication for bipolar disorder while BPD requires a specific type of psychotherapy.
EM: If you had a loved one in emotional or mental distress, what would you suggest that he or she do or try?
BG: First I would try to identify priorities—which type of intervention would best fit depending on the problem, the person’s sensitivity, their openness, and their access to potential treatment.
I would listen and try to grasp the basics of the problem, making sure I understood correctly, then share what I think and, if I feel it is necessary, to say why I would recommend to see a mental health professional. Along the way we can also discuss the importance of some life changes, from exercise to diet, to the need to see a primary care physician and get some lab tests, as well as the advantage of meditation, yoga or AA and the importance of limit setting at work or the need for a vacation.
I might recommend a psychiatrist or a psychotherapist and I always describe what, in my opinion, would be the important qualities to look for. The quality I value most in mental health professionals is the ability to listen and to take the time necessary to do a good job in the evaluation and treatment. Knowledge and expertise and experience are important, but even more key are the human qualities of the practitioner–empathy, humility, curiosity and honesty.
I look for a practitioner aware of what he knows and what he doesn’t know, solid, flexible, creative and able to adapt if the prescribed medication doesn't work or if the patient prefers not to take them. Last but not least, I would look for someone who works with his or her client, fully answers questions and explains, at least in part, what he or she is doing with the patient and why.
Bernadette Grosjean, MD. has practiced psychiatry for 30 years. She is Associate Clinical Professor of Psychiatry at UCLA School of Medicine and works currently at Harbor UCLA (California). In 2014, she co-authored "Le Manuel du Borderline" (Eyrolles, Paris) the first comprehensive guide in French about BPD for patients and families.
Eric Maisel, Ph.D., is the author of 40+ books, among them The Future of Mental Health, Rethinking Depression, Mastering Creative Anxiety, Life Purpose Boot Camp and The Van Gogh Blues. Write Dr. Maisel at email@example.com, visit him at http://www.ericmaisel.com, and learn more about the future of mental health movement at http://www.thefutureofmentalhealth.com
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