DJ Jaffe's Insane Consequences: How the Mental Health Industry Fails the Mentally Ill is a well-informed, unapologetic critique of the mental health industry in the United States. The book examines many systemic problems that have led to an overwhelming deficit of resource allocation to serve people with severe mental illness. While an estimated twenty percent of Americans are affected by any mental illness, it is the four percent of adults with persistent and severe mental illness that need the most help. Based on evidence cited in this book, patients with untreated severe mental illness are at increased risk for detrimental consequences that include homelessness, suicide, involvement with the criminal justice system, and violent behaviors.
In plain language, Jaffe presents a clear and compelling argument divided into seventeen chapters, along with an appendix and footnotes that further substantiate his arguments. The chapters are organized into seven thematic sections. The first two sections frame the discussion with an overview of serious mental illness (SMI), defined as schizophrenia spectrum disorders, major bipolar disorder, or major depression diagnosed in adults. The next three sections introduce major participants in the mental health industry (i.e., Substance Abuse and Mental Health Services Administration, Copeland Center for Wellness and Recovery, Bazelon Center for Mental Health Law, Mental Health America) and document the ways in which they reject scientifically based treatments in favor of unhelpful programs claimed to be evidence based. Section six identifies federal policies and U.S. Supreme Court decisions that have impeded access to treatment for people with SMI, and section seven introduces potential solutions and a proposed reallocation of existing resources to optimize existing programs.
Jaffe, who died in September 2020, was an influential critic of the mental health system and self-proclaimed mental illness advocate for over thirty years. His advocacy work focused on severe mental illness and was largely inspired by his personal experience with a family member. The author served on boards of nonprofit organizations, including the National Alliance on Mental Illness and the Treatment Advocacy Center. In 2011, he founded and served as the Executive Director of Mental Illness Policy Org. Throughout his career, Jaffe made substantial contributions toward shaping mental health legislation, including New York's Kendra's Law and the 21st Century Cures Act.
Insane Consequences provides historical context regarding the deinstitutionalization of severely ill psychiatric patients through a summary of major federal initiatives and policies. The text describes how the movement toward deinstitutionalizing people with mental illness gained momentum in the 1970s, resulting in a decrease in hospital bed admissions with an expectation that community agencies would provide adequate treatment and housing. Community support for the most severely ill turned out to be significantly lacking, resulting in the same patient population being re-institutionalized in the criminal justice system. Jaffe additionally details how privatization of community treatment further selected for the most profitable patients and neglected those with persistent and severe conditions. Chapter 14 chronologically documents the federal government's failed attempts to reform the mental health system since 1946. While deinstitutionalization and lack of funding are acknowledged as contributing factors to the problem, Jaffe asserts that the fundamental matter is that the mental health industry and mental health advocates have consistently chosen not to focus their efforts on the most severely ill patient population.
Throughout his book, Jaffe makes a clear distinction between “mental health” and “mental illness,” focusing the scope of the discussion on the ten million patients with SMI. He highlights how these patients generally receive the least amount of help from community programs and are consequently unable to maintain a high level of functioning. According to Jaffe, consequences of untreated SMI are not easily palatable, resulting in a tendency for mental health service providers to be dismissive of this inconvenient reality: “not everyone recovers, sometimes hospitals are necessary, involuntary treatment is preferable to incarceration, and there is a group of the most seriously ill who left untreated become suicidal, homeless, criminal, incarcerated, and yes, sometimes violent” (p 23).
Jaffe does not refrain from casting blame on a number of mental health organizations and specifically criticizes the Substance Abuse and Mental Health Services Administration (SAMHSA) for their promotion of the “recovery model” in place of a more scientifically based “medical model.” Despite evidence supporting the effectiveness of medications and electroconvulsive therapy, intensive case management, assertive community treatment, and assisted outpatient treatment (AOT), Jaffe posits that insufficient funding has been allocated toward these proven strategies. He strives to further expose the mental health industry for its track record of obstructing involuntary treatments, opposing psychiatric hospitalizations through the Institute for Mental Disease (IMD) Exclusion in Medicaid, and openly expressing biases against the use of medications as evidenced by anti-medication advocacy groups.
Jaffe asserts that to date, the mental health industry is largely composed of groups that have continually convinced the government to divert funding toward programs that are not evidence-based. Billions of dollars are spent on programs targeting broad definitions of “at risk populations” and “prevention,” which lack rigorous research methodologies evaluating outcome measures and fail to de-monstrate clinically meaningful outcomes. One key takeaway, according to Jaffe, is that there is plenty of funding available, 238 billion dollars, but the sickest patients are not receiving the care they need because of an inappropriate allocation of funds. In addition to advocating for increased access to the community programs mentioned above, Jaffe is a proponent of solutions that prioritize the most severely ill: eliminate the IMD exclusion in Medicaid and Medicare's 190-day lifetime cap on psychiatric hospitalization; reform SAMHSA and dissolve anti-treatment Protection and Advocacy Groups; amend the Health Insurance Portability and Accountability Act and Family Educational Rights and Privacy Act to include parents or caregivers in treatment decisions; fund and optimize mental illness research; implement court supervised programs (AOT, mental health courts); and provide standard training to all law enforcement officers, who regularly interact with individuals with SMI, on the basics of mental illness and how to connect such individuals to treatment.
This book effectively conveys a powerful message that the current mental health system fails the most severely ill patients. While the tone and delivery is provocative and relentlessly critical of agencies within the mental health industry, it is an approach that highlights the importance of this matter and the urgent need for mental health policy reforms. Overall, this is a worthwhile read for forensic practitioners or those in the mental health workforce with an interest in criminal justice, homelessness, and public policy.
Footnotes
Disclosures of financial or other potential conflicts of interest: None.
- © 2021 American Academy of Psychiatry and the Law
