Listening, learning, doing no harm: The evolution of mental health care

If your idea of what goes on in a mental hospital is mostly based on “One Flew Over the Cuckoo’s Nest,” you’re not alone. Recent studies show that even primary care physicians don’t necessarily have a high level of experience and familiarity with mental illness.

"Mental illness is very real," said Anthony Blanford, a Wellpath employee and staff psychiatrist at Alaska Psychiatric Institute. "It causes a lot of suffering. A lot of the most severe suffering is out of the public eye."

Institutionalization in state hospitals like API used to be the only option for patients who experience schizophrenia and other severe mental illnesses. But in a few short decades, much has changed about how mental illness is managed and treated.

This World Mental Health Day, we asked Blanford and his colleague Kevin Ann Huckshorn, Ph.D. -- a consultant with Wellpath Recovery Solutions, the private company that began providing consultation and support at API earlier this year -- to reflect on how mental health care has evolved and improved. From better research and more consistent diagnoses to advances in medication and addressing power imbalances, here’s a look at some of the advancements in how we approach mental health.

JFK’s legacy of deinstitutionalization

Huckshorn was a young nurse sitting in a graduate school classroom in 1985 when she watched “Titicut Follies,” a 1967 documentary that portrayed horrifying mistreatment and shocking conditions at Massachusetts’ infamous Bridgewater State Hospital.

"I remember thinking at that time, 'I am going to go into mental health because if this is what's going on with treatment, they need a lot of help,'" Huckshorn said.

While most state hospitals weren’t nearly as bad as Bridgewater, by the 1960s leaders recognized that there was room for improvement across the board.

"Most states had literally thousands of people locked up in what used to be called asylums," Huckshorn said.

President John F. Kennedy's Community Mental Health Act of 1963 introduced "deinstitutionalization" as a national priority. The legislation, signed just a few weeks before Kennedy’s assassination, was intended to reinvest state psychiatric hospital funds into mental health services so the severely mentally ill would have the support they needed to live in the community.

Over time, about 90 percent of state hospital beds nationwide were eliminated. But the corresponding community-based outpatient resources never fully materialized. Only half of the proposed community mental health centers were ever established, and there was no provision for long-term funding, leaving it up to individual states to fund their own services.

Although the promise of the Community Mental Health Act was never fully realized, its passage permanently impacted mental health treatment in the U.S. Access to mental health services is now a growing consideration nationwide even as a majority of Americans now see mental health as equal in importance to physical health.

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Advances in diagnosis and treatment

The history of psychiatry is riddled with questionable treatments, from pulling teeth to deliberately causing insulin shock as a way to manage symptoms of schizophrenia.

"It was absolutely crazy back then," Blanford said. "Some of it was desperation."

Although medication alone isn’t a cure-all for severe mental illness, Huckshorn said the development of thorazine in the 1950s was a major turning point. At the time, more than half a million Americans were institutionalized with mental illness. The new antipsychotic medication started to make it possible for many patients to recover enough to be discharged.

"It basically replaced insulin shock, lobotomies, and electroconvulsive treatment, which was way overused back then," she said. New antipsychotics and antidepressants followed in the 1970s and 1980s, continuing to expand the range of medication options.

The advent of antipsychotic medications came at around the same time as the development of the Diagnostic and Statistical Manual of Mental Disorders, or DSM. Its publication marked the first time that a single mental health vocabulary was in use around the globe, bringing consistency to diagnoses that had previously differed significantly from country to country or provider to provider.

"We got more consistent and reliable on what we were treating, what we were even talking about," Blanford said. "That doesn't mean we have it exactly right now, but we have a much better idea of what we're trying to deal with. There's a much better level of standardized care."

Contemporary mental health care is guided by evidence-based practices -- courses of treatment and therapy based on research.

"Evidence-based practices are quite different from the '70s and '80s when everybody used to sit around a table and try to figure it out," Huckshorn said. "Now, if you choose an evidence-based practice to implement and have thought about what you'd like your outcome to be, you're much more likely to reach that outcome than just flying by the seat of your pants."

The expanded body of research and evidence-based practices also means there are more paths to consider for each individual patient.

"The biggest thing, I think, is the options for treatment have expanded greatly," Blanford said. "It's still an inexact science, but the options are there."

Understanding and preventing trauma

Prior to the early 2000s, trauma treatment was considered something that was needed only for patients who had survived combat, domestic violence, or rape, Huckshorn said. That all changed with groundbreaking research into childhood trauma -- called the Adverse Childhood Experiences research study, or ACEs -- and its long-term effects on physical and mental health.

Today, mental health practitioners are trained to be aware that a patient may have experienced trauma and to be prepared for how that might impact their care.

“We have learned so much about how to be more trauma-informed when we’re providing services,” Huckshorn said. “Our first mantra is to do no harm. Being trauma-informed means that you run much less of a risk in re-traumatizing (people in care).”

It’s an important consideration at facilities like API, where patients are often combative. Reducing the use of restraints and seclusion is a priority in the mental health care field. These once-common practices, known to carry the risk of physical and emotional trauma, are now considered a last resort.

"There is a power imbalance between the service provider and the service recipient, and that can be dangerous,” Huckshorn said. “You run the risk that power can be abused, even unconsciously. It's our leaders' responsibility to watch for that, to train our staff to watch for that, to take immediate steps if we see any abuse of power, because that is directly opposite trauma-informed care principles."

Humanizing psychiatric care

One of the most significant developments in mental health, Huckshorn said, has been a shift to involve patients -- current and former -- in care decisions.

"In the 1950’s and 1960’s a number of people who had been patients in state hospitals or patients in the public mental health system got together and said, 'Something's wrong with this system; it's not very compassionate, it's not very responsive, it's not very good,'" Huckshorn said. "They came out and said, 'We need to get involved in the provision of services.' It took us a long time to listen.”

That was more than five decades ago. Now peer services are commonplace, available across the country and considered a best practice by the federal Substance Abuse and Mental Health Services Administration.

"(Peer specialists) work in mental health settings, side by side with regular staff," Huckshorn said. She likened the role of a peer support worker to a sponsor in the Alcoholics Anonymous structure -- someone to help a patient "navigate their recovery and stressors of daily life."

The value of listening and understanding can’t be overestimated, Blanford said -- especially when working with the patients he sees at API, who are often combative.

"The patients can be tough," Blanford said. "We get people who are mostly psychotic and not connected to reality as it stands. You have to figure out what's contributing to it. We try and manage any environmental or staff triggers for these individuals."

Blanford recalled a patient with schizophrenia, years ago, who was striking out at other people.

"I took some time to sit down and decipher what he was communicating," Blanford said.

It turned out the man also had glaucoma and wasn't getting his medication. He was in pain.

"You have to be really careful that you're not missing something like that," Blanford said.

Blanford said above all, his approach to his patients is rooted in empathy.

"Everybody is somebody's family, right?" Blanford said. "Everyone is someone's child, parent, wife. No matter how bad it looks, somebody is somebody's loved one. I ask myself, 'If this were my son, what would I want done?'"

Presented by Wellpath Recovery Solutions in observation of Oct. 10, World Mental Health Day. Learn more at wellpathcare.com/api.

This story was produced by the creative services department of the Anchorage Daily News in collaboration with Wellpath Recovery Solutions. The ADN newsroom was not involved in its production.