Why do people who need therapy not go to therapy? Obviously, there are real, practical barriers, like geographical location and affordability. There are systemic obstacles, too, recently documented in two recent, devastating articles on homeless, severely mentally ill people in New York and Washington, DC respectively (https://www.nytimes.com/2023/11/20/nyregion/nyc-mental-illness-breakdowns.html and https://www.washingtonpost.com/dc-md-va/2023/11/21/dc-preschool-attack-homeless-mental-health/). And there is the agonizing case of the Maine gunman, Robert Card, who colleagues and family knew was decompensating and made an effort to intervene, but failed to get him help (https://www.nytimes.com/2023/11/02/us/maine-shooting-mental-health-laws.html). Not everyone who needs help is responsive; nevertheless, this should not obscure that some people who would like to get help do not receive it, and that too often we fail in engaging difficult patients.
Although stigma has decreased, mental health problems continue to raise a red flag in certain professions and thus impact people’s willingness to seek help—as well-indicated in the saga of the airline pilot, Joseph Emerson, who, fearing that medication for his depression would sideline him from his career, ended up taking mushrooms and becoming sleepless, and then traveling as a passenger in the cockpit of an airplane, growing restless and attempting to take it down (https://www.nytimes.com/2023/11/10/us/alaska-airlines-pilot-joseph-emerson-mushrooms.html). In this newsletter, I will explore issues around the psychological factors that at work when people who need help do not receive it, which are too taken for granted or barely recognized. It is agonizing, but necessary to reflect upon aspects of what happened in the aforementioned news items, as we can learn from such cases and perhaps become more successful at ensuring that treatment, including psychotherapy when appropriate, is a readily available option.
Both the NY Times article by Amy Julia Harris and Jan Ransom and the Washington Post article by Peter Hermann, Keith L. Alexander, Tara Bahrampour, and Omari Daniels focus on the revolving door, wherein severely mentally ill, homeless people cycle through custody and brief hospitalization (that sometimes does not even include stabilization before being released back into the same communities) The journalists in the Times article are careful about not insinuating that the mentally ill are violent and note that mentally ill, homeless people are far more likely to be victims of crime than to commit it. The journalists in the Post article focus on one person’s story, Russell Fred Dunkley III, who attacked, exposed himself, and terrorized two teachers who were on a walk with toddlers in the gentrifying neighborhood in Washington, DC, Bloomingdale, in which he grew up. The article characterizes Dunkley as schizophrenic and is empathic about his sister’s wish to be able to help her brother, but it does not address what it would mean for him to get help. The Times article provides more detail about treatment options and documents the experience of several people—some of whom resist treatment and some of whom wish that treatment was more easily available. In New York, there is an alternative option for people to be brought to designated mental health shelters that are staffed by social workers and psychiatrists. However, emergency medical technicians (EMT) or the police do not always bring homeless people to those shelters. When people are brought to hospitals, they are often refused admission or released before they are stabilized. It is often the case that mental health treatment only becomes an option, once someone enters the criminal justice system. Harris and Ransom zero in on a crucial element that helps us to explicate the point at which things frequently go wrong:
A network of special treatment teams was supposed to be
New York’s solution for caring for high-risk, mentally ill people
on the streets, but more than a dozen cases identified by The
Times occurred on the watch of such teams. The failures took
place as the state has starved the teams of funding, leading
providers to pay caseworkers low wages and saddle them
with staggering caseloads. Some teams spent just 15 minutes
per visit with patients — the minimum amount of time required
to bill Medicaid for services.
This is shameful and counterproductive. Harris and Ransom provide further disturbing evidence—for example, about a man named “Newton” who simply denied any mental illness, despite having a long history, which was taken for granted without further inquiry by the intake worker. After a few misplacements, Newton ended up on the streets, where he made headlines, striking a man with a hammer in Union Square. After being sentenced to 8 years in prison, Newton reflected that: “My mind was unstable… I didn’t take the time for myself to get in line to talk to someone or get my meds.” Although Newton suggests that he could have availed himself of help, it is not clear what kinds of treatment were offered to him.
Michael J. Jones is another case discussed in the Times article. He sought out help from a hospital but was turned away with the suspicion that he was merely seeking the comfort of a warm bed. He had history of benefitting from medication and came to the hospital because he was concerned that he might hurt himself or someone else. After being denied admission, he ended up getting in an altercation with the police and being sentenced to 10 years in prison. In his understanding, he was denied the help that he knew he needed.
There is no question that the homeless, mentally ill present especially challenging problems for the mental health system. As a psychologist, I cannot help but notice that, for some reason, psychologists are not represented at the designated mental health shelters and, it seems, no qualified professionals are utilized on the special treatment teams that are supposed to assess people and determine appropriate next steps. Talk about penny wise and pound foolish.
The horrifying case of Robert Card, the shooter who killed 18 people and injured 13 people in Maine (and then committed suicide), has centered on loopholes in the system, which clearly failed. Card had become paranoid and heard voices, resulting in being hospitalized, relieved from his job in the Army, and rejected for purchasing a gun silencer (even though, it seems that he had been able to purchase guns). There was an attempt to make a welfare check at his home, but he was not at home (there was a second attempt the next day, but no follow up). Given the circumstances, one might expect that a missed welfare check would kick in greater concern about risk, but that failed to happen. Card presents a tough case, as he was not in a mental state where he would assent to treatment willingly. Hospitalizing someone like that seems both in his self-interest and the best interests of society. Still, much is unknown about Card, and I have not seen anything in the news about any previous history of mental health treatment.
Joseph Emerson, the airline pilot, claims never to have taken mushrooms prior to the incident in question.[i] He did have a history worthy of notice: he had been bullied as a kid, sent to therapy, then struggled with an alcohol problem, and had been depressed for the last 6 years, which intensified more recently with the death of a close friend. He described himself as having “longstanding mental health issues,” and at some point, was seeing a therapist. His wife reported that she had been urging him to seek help because of his response to the loss. His solution was to turn to a hallucinogen. Not the best decision, but not surprising, given that hallucinogens have received so much positive attention and, more generally, that people turn to all kinds of medications as a way to alleviate mental suffering.
As already mentioned, Emerson had good reason not to get help for his depression, if it would mean being sidelined from work. His case raises a point that is speculative but worth pondering. Many people know they might benefit from therapy, but they do not pursue it because of fears about what it will be like. This is a factor that should be more widely recognized and, ideally, encounter responses that would serve to encourage someone to move forward and give therapy a try.
Mental health professionals can do a better job of realistically explaining how therapy works. I am completing a book that uses memoirs that include descriptions of therapy—the voice of patients unmediated by therapists’ or researchers’ perspectives—in order to highlight their actual experience. Interestingly, most of these memoirs are about psychoanalytic therapy. CBT memoirs are hard to find, although there are lots of self-help books from this perspective. We still need therapists to write about their understanding of the process, especially in a form that specifically aims to address the concerns of someone who is open to but tentative about starting therapy. A further reason that we need such literature now is that we are facing competition from less than scrupulous sources that are happy to make hyperbolic declarations about therapy.
So, I am suggesting that new efforts ought to be made to reach people who might want to try therapy but are hesitating, and not infrequently experimenting with alternatives. Perhaps, this sounds like reinventing the wheel, since there is overlap with motivational interviewing, where one is assessing someone’s readiness to change. What I have in mind, though, differs in being more psychoanalytic, meaning that the generation of conscious responses is understood as only part of the story. When possible, I have found that it can be helpful to conduct an extended consultation period, without pressuring potential patients to get ahead of themselves.
The issue of engaging people who are on the verge of therapy is markedly different from more recalcitrant cases, I realize, where the person needs but refuses help. Our efforts might fail, no matter how qualified and experienced the clinician. However, people who have long mental health histories can be savvy in picking up how skilled and thoughtful the clinician is with whom they are interacting. The training that mental health professionals acquire equips us to hang in there with patients under difficult circumstances, to listen well and not just check boxes, and that deserves to be recognized and respected.