xxAACP Newsletter, Volume 11,
Number 1, Winter 1997
Editor's Column: Using Street Smarts
"She's handling her disability check okay, but she has no money."
"I just want a chance to work but there are no jobs."
"We consumers are survivors;
We don't trust psychiatrists until they show they can be trusted."
"She often forgets to take her meals."
"I am worried about her kids. She is using and her benefits are cut off."
"His lover has HIV."
These are some of the voices we all hear at work. Coming from case managers, therapists, family members and, of course, the consumers of our services, our patients. They flood us with information. Do we know how to listen to all of it? Do we know how to use it? I am not sure we do, on either count.
We tend to focus on the pathology of individuals. We listen for signs and symptoms of mental illness. This has been reinforced by the increasing emphasis on being placed on biological psychiatry in this decade of the brain. We look for DSM-IV symptoms and, increasingly, rely on medication as our major contribution to care. But even before the rise of biomedicine, in the era of psychotherapy, we usually paid attention primarily to the person in our office, isolated from their social context. We frequently practiced as though each patient was completely separate from the next (except for their common pathologies). We did not see them and us as being bound together by the community and social context we share. Wo we practiced psychiatry on an individual level, one case at a time. In a bubble, as it were.
The world has a way of intruding. In addition to biological psychiatry, the last fifteen years has seen the use of assertive community treatment teams, case management, and the consumer and family movements. These are the sources of the new voices we are hearing. They are coming in with news from our communities that we ignore at our peril. It is news about the "real" world, the world at street level. From them we know how poverty, stigma, and racism impinge on our patients, how families cope and how consumers recover. We learn about the absence of work, the struggles to get disability, and shortage of housing. We are forced to acknowledge the vast impact of the social world and public policy on our patients.
There is another new voice to acknowledge. That is our voice, the voice of the American Association of Community Psychiatrists (AACP).
It is my contention that we, as a profession, must speak up about what we are being told. We must say that the conditions of poverty our patients live in are intolerable, that the stigma and racism and sexismm we hear about every day must be confronted because, among other things, they are damaging the health and mental health of our patients and our communities. We must strenuously call for resources to support the families for which we provide care. We must support the efforts of consumers to recover and to provide mutual aid for each other.
To speak up on these concerns will throw us fully into the argument going on about the role of government in our society and the nature of social welfare programs. To some degree, we are already engaged in this nationwide discussion as we have focused on the issues of providing publically funded mental health care services in this era of managed care. That is well and good.
But I want to suggest that we must expand our concerns to include such topics as welfare "reform," housing policy, urban and rural development, education policy, and disability policy. We must tackle the race, gender and age issues that riddle our society.
How do we do this? We are, after all, just a small voice. To begin with, we do not have to do it all at once. We can prioritize. Nor do we have to do it alone. There are many organizations working on these issues with whom we could partner. Our job in this is to organize and convey what the voices we hear at work are telling us about the world around us and add our won. To do this we must accept the fact that we cannot limit ourselves to one patient at a time, or solely to biomedical concerns. What must concern us is not medical necessity, but what is relevant to the health of the people and community we serve.
Let me suggest where we might start. We are already getting into the maelstrom of managed care Medicaid. We must also examine welfare reform and its impact on our patients. We must also begin to work with the consumer movement and help build the "recovery movement" that is underway.
We get the knowledge every day and we are street wise. It is time to use what we know and add our voice to those of our coworkers, of families and consumers.
Kenneth Thompson, MD
Associate Editor
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