WMH Season 4 Ep 2: Rethinking How We Treat Mental Health in the Community

This is a transcript of Watching Mental Health Season 4, Episode 2 which you can watch and listen to here:

Katie: Hi everyone. Welcome to another episode of Watching Mental Health, and I am so excited today because we have a leader in the space on today, and we're going to talk about something that I don't get a chance to talk too much about. And that's community integration, that's treatment for substance use, for mental health conditions. And I want to tell you a little bit more about our guests before we bring them on. So Dr. Ross Ellenhorn, excuse me, is a thought leader in helping individuals diagnosed with psychiatric and substance use issues recover in their own communities outside of hospital and residential settings. So something a little bit different than what we're typically seeing. Traditionally, he's the founder, owner and CEO of a robust community integration program here in the United States. And he gives talks and seminars to mental health agencies, psychiatric hospitals and addiction programs throughout the states as well as Europe. And today on watching mental health, we're going to be breaking down his thoughts on community treatment versus inpatient settings and talk more about what's missing in our mental health system here and in our treatment across the country, why we continue to struggle in these spaces. And so with that, let's bring on Dr. Ross Ellenhorn to the show.

Dr. Ross: It's nice to be here.

Katie: Thank you so much. I do really appreciate it. It's really great to have a leader in the space on your PhD. You've been doing this work a long time. So before we jump into anything, tell us a little bit more about who you are, your background and why mental health treatment really matters to you, why you wound up in this space.

Dr. Ross: Yeah, I mean, there's a couple roots to talk about. One is I'm actually trained as a sociologist, so I have this interest in this crazy idea that our social experience is actually important on how we experience the world. It's really a kind of central missing element in most mental health care, even though everybody, basically, when they think about what affects them, it's the social things going around

Them. And yet in mental health care, we act as if everything's skull bound, like the person isn't experiencing something in the world or that their struggle is about being a mental health patient, that the very active kind of being in treatment has an effect on a person socially. So I've also trained as a psychotherapist. So it's just that combination that kind of brought me to community integration. And then the other route is that I was diagnosed with a really significant learning disability at a young age, and that diagnosis probably had a greater effect on my functioning than the actual disorder. I don't even know what that disorder is, a PhD and three books behind me. I don't know what this thing was they were calling a learning disability, but the label of it and theorization of me, the people kind of making decisions about who I was affected, my thinking about that experience for a lot of people, this kind of labeling of sick and broken, the selling of cures, as if that there's some way in which we can kind of fix a person through some sort of technique and stuff, I think is often more injurious than the actual psychiatric event going on.

And so that kind of affects my thinking about, well then how do you help people still keep, contain and keep their value in the community and a sense of purpose and all those things while they're getting help for whatever's going on, causing them psychological suffering.

Katie: Yeah, definitely. And that's really interesting because that's traditionally what we see is this labeling, this kind of selling of cures to try to deplete or get rid of whatever symptoms that they're experiencing. So as you have gone through your career, have you seen not just within what you experienced, but with others, with other patients, that labeling and that kind of maybe taking control away from them in some ways that they don't have any power over what their treatment looks like? How have you seen that play out?

Dr. Ross: I think that it is a motivation destroyer that the things that we see when we talk about people that are struggling is typically someone who won't engage in treatment,

Won't engage in the process of change and won't really kind of move forward in life. And I don't think that's necessarily the psychiatric event that's causing it. It's the experience that they've been kind of experiencing themselves has broken. They've been through massive disappointments over and over again. I do this research on a thing called Fear of hope, and that they lose this sense that they're allowed to hope. And so it just slows down their ability to change. And then it doesn't matter what diagnosis they've been giving given that's been going on. And even the advocacy for mental health care is profoundly stigmatizing that this idea that we're going to unstigmatized people by saying that they have the problem is a broken brain is insane. It is stigmatizing stigma was invented by cultures to keep sick people out. And so why would we ever think that saying, don't stigmatize these people, they're sick in the head, would do anything but stigmatize mental health. The opposite of mental health is sick in the head. The opposite of behavioral health is sick behavior. And so all these words we use that we think we're using to kind of free people from this stuff is profoundly stigmatizing.

Katie: We, it's right in the sentence,

Dr. Ross: But it's not just stigma, it's the way treatment's delivered.

That if you don't show up for treatment, you're being resistant. You're being non-treatment compliant, and often because you're having such acute experiences, we should lock you away and make you do something that's really hard for someone who's having psychiatric events, which is live with a bunch of people that are supposedly have the same diagnosis of you. Try to get along with them, all of that, and then make your life all about getting better, which is insane to live a life where basically every day people stand over your bed and say, is this the day when you're changing? Will this be the day you change? Yeah. So that element also is maddening, creates all these problems. We really do have a factory system of mental health in this country, one in which you're broken, then you get sent somewhere and supposedly they fix you and then you come out. And the problem with that in mental health and addiction is that the medicine is dignity. The medicine and the thing we should be trying to achieve is dignity, and the medicine is purpose, and the medicine is having some sense of social value and social support. And without those things, people don't change. So why are we not delivering those things in our care? And that's where community integration comes in.

Katie: Yeah, definitely. And so the medicine isn't medication, it's this community integration, and you have programs from my understanding that you've utilized or that you've developed. So tell us more about how you've changed your approach from this kind of traditional approach of taking someone, calling them sick, locking them up and waiting until they get better, so to speak.

Dr. Ross: Yeah, yeah. Well, the remarkable thing, and the average response to this, which is the response you're giving, which is completely understandable, is that this is a new thing or it's innovative.

This is what community mental health is. So when they deinstitutionalized, when John F. Kennedy, deinstitutionalized Hospitals, they created a bunch of programs in the United States that were about how to get people to reintegrate in the world. That's what that was. So the number one way we treat people in this country is actually mostly community integration. It's just not done at a private level, and it's not done for insurance. But if you're a person that's using your Medicaid or community funds, which are dwindling in this country, but public funds, you're going to go to a place that's going to have supported housing, supported employment, a clubhouse model. It's going to be all about how do we get you to be a part of the world again? But that's only been in community mental health agencies. It never spread out to private care because insurance won't pay for it.

Katie: So how do you get insurance to then play into this kind of model?

Dr. Ross:

I don't know. I mean, I think you make the argument, which is true, that this is the model that lowers the expense of hospitalizations, but it isn't a cheaper model than therapy. It requires more human power to do community integration than seeing a therapist once a month or once a week.

So I'm not sure the answer because you can't quite sell. Its cost cutting, but I'm not in the business of cost cutting. I'm in the business of helping people recover. Right, exactly. And our government shouldn't be in the business of only cost cutting. It should be what works, what helps our fellow citizens.

Katie: That's interesting. You're on the east coast. I'm on the west coast. I'm in Nevada. We're one of the worst states for mental health. I think that the mental health American numbers just came out where 51 out of 51. Again, it's a struggle here in our state. And so I find that community integration here in the state is in some ways it is that kind of innovative thing that nobody can wrap their fingers around because we're struggling in these old antiquated ways. Now, you've traveled the country and Europe really talking about these things. Have you noticed that some places, maybe certain states or certain areas where they're better integrating these types of services and others where they're really still struggling?

Dr. Ross: Yeah. Yeah, absolutely. I mean, everybody's struggling right now regarding mental health services because just every year they're cut and cut and cut. But I mean, Ohio is really good. Boston's really good. LA is pretty good. My programs are in Boston, LA in New York, so I kind of know those areas. So there are places that are good, and you'll hear about this, they're often talk about our program is what's called pact. It's a model. It's like a hospital without walls or ACT programs, but anywhere where there's case management, you're talking about community integration on some level that still is in the community. Anywhere you hear somebody talk about supported housing, I bet you Nevada has some sort of supported housing. At least something's going into

Katie: That. Yeah, we do. We've started with community health workers as well, peer support specialists. Those are all relatively new to the state, but they've been around a long time.

Dr. Ross: Yeah, but it's great that you have 'em, because the other thing that can happen is that community integration becomes almost like probation officers. So the other problem is that when you start going out to people's homes, is it about surveillance, making sure they're okay, making sure they're not doing anything that's weird in the community, or is it about their recovery? And that could switch very quickly. Case management, departmental health case management. Is it therapeutic sometimes or is it actually about social control, keeping track of the clients? So it's often about the spirit of the place. How are they thinking? How are they training their staff?

Katie: Yeah, absolutely. So tell me more about your programs and the results that you've seen from your programs.

Dr. Ross:

Yeah, so we're the most robust community integration program in the United States. We really were taking community mental health models and delivering it to actually pretty wealthy people In some ways. It's not like I feel bad for wealthy people, but the fact is is that they really have a system, especially when we started 20 years ago, where you're seeing a psychiatrist and then you're going in the hospital. And the gap between those two things where most of the work for a person is happening was empty. So we filled that. So we see people up to 30, 30 hours a week individually. 80% of what we're doing is out in the community, but it's not about delivering therapy to people. It's about how do we keep you in school? How do we keep you at work? How do we do all those sort of things? Again, that's the medicine. I have no doubt about it. And so also, how do we help a person rebuild faith in themselves? That's really how do we help the person rebuild pride? People just will not change. If those things aren't there, they won't do it. So we have this system where it's like, here's the best practice therapy. Here's the best practice therapy. As if every person that walks in, if they don't accept what we're giving them, something's wrong with them or they're too sick instead of they can't do it because they don't have enough social stuff going on around them to allow them to be able to engage in a way. And so we're trying to get to that place. For me, the successes are people who can autonomously be getting help. We work with people who've been so harmed by going in and out of the hospital that our job is to help them rebuild enough faith to feel like they are in charge of their treatment. Nobody changes if they don't feel like they're the one guiding the treatment. So to get them there, we say that. I say that if somebody comes to you in my program and says, that thing you told me last week, I thought about it and I applied it, and I really liked using it. They're done with our program. That person does no longer needs a hospital without walls. We meet every day for rounds at a hospital psychiatrist there, everybody talking about the last 24 hours. We do that every day of the week, every weekday. Lots of people don't need that. We're dealing with the people that are struggling so hard that they need that constant kind of way of a group of people thinking about that at all times.

Katie: Yeah, yeah, absolutely. I love that approach that you're looking at recovery not just from the mental health symptoms, but from their social interactions, from how they feel about themselves and how they interact with the world around them. And that's so important that I think a lot of people ignore when they're in that kind of treatment setting where they're really only focused on, okay, let's make it so their hallucinations go away, or so they're not so depressed, but it's like, well, there's this whole other section over here around socializing social skills that are just as important to get somebody to reintegrate in society.

Dr. Ross: Yeah. Yeah. I appreciate you calling 'em social skills, but what I mean is what we're called social resources. So, social resources are things like a sense of effective in the world. I have social support. These are very powerful things for all of us that affect motivation. So there's a thing called threat assessment theory, and they study this using people's physiology in response to threats. And it basically says that a threat is something where you don't feel like you have enough resources to meet it. And a challenge is something where you feel like you have enough resources to meet it. So if you're out in the cold in a t-shirt and snowstorms hits, that's a threat you put on a jacket, it's a challenge. Social resources are like that about our motivation towards change. So the smallest thing can look like a threat if you don't have a sense of social support, a sense that you're effective, a sense of pride, all those sorts of things. If you don't have those, looking at your own problems as a threat, seeing a therapist as a threat, all of those things that gets labeled as in denial or treatment resistant,

But that person's not treatment resistant. They're scared. They don't have enough resources. You're exactly the same as that. I am too. If I have a bad week and someone wants me to talk about being introspective of my own problems, I'm not going to do it. So that's just like an element. We don't afford that to mental health patients. But the fact is, if we don't change that part of their existence, and I totally believe in treating symptoms, but only because they're getting in the way of a person having a meaningful life, I just have no interest in treatment, symptom reduction for symptom reduction. It means nothing to me. So if I have a patient who hears voices and is married and has a job and kids and a good life, or a patient who is basically tranquilized on antipsychotic medications and doesn't hear a single voice, I'm picking the first one. If I have a person who moderates their drinking but has a good life compared to someone who's living in hell, who's in absence, I'm picking the first one. So it's not about the problem. The problem often gets in the way of getting to the thing we're trying to get to, which is a better life, a life of pride, a life of dignity, a life of contribution, all those sorts of things. That should be our target. And that takes, yeah, go ahead.

Katie: No, that's interesting. That's just an interesting perspective. I love that.

Dr. Ross: Yeah. Yeah. It's not original. It has been overtaken, especially in the last five or six years with all these techniques about fixing people.

Katie: Right. Well, we're so diagnosis happy, I think. And then some diagnoses are real trendy right now. It's very trendy to be autistic and a DHD, and you see this kind of stuff on social media. And so that's interesting to me, and I've noticed that the way that you're talking, you've not once used a diagnosis or a label like somebody maybe is hearing voices where somebody may call a certain label. You're really being mindful to not use those terms. So talk to me a little bit more about that, about just your thoughts on how it does seem like society is very label happy, and maybe there is a good thing to that, but maybe there isn't. So tell me more of your thoughts on that.

Dr. Ross: Yeah. Well, I mean, one of the major trends right now is a real problem called trauma failure. That's the obsession with seeing trauma and everything,

And our field is suffering from that disease. It really has a problem with that disease. Not that there isn't a lot of trauma, but trauma does not describe every event. It ends up dignifying the person as much as any diagnosis to say, to not see the uniqueness of each person's trauma, but to start talking about trauma as a thing that is shared in the same generic way with each person. It actually is a kind of blasphemy regarding the powerful uniqueness of every person's trauma. It actually hurts trauma. It hurts the idea of trauma to make this thing where everybody's the same in what happens to them. And then you kind of have this treatment that works for every single person.

Katie: We're trying to generalize their trauma and their treatment.

Dr. Ross: Yeah, exactly. Yeah. And then it also becomes this thing that describes everything and the meaning of the event, the meaning of the event's, the important thing, and it gets lost. What does the meaning for each person's individual experience to change a person? The first step is to build a relationship with your suffering. A diagnosis can help in that.

I now understand what this thing is. They're calling depression, and now I want to understand who I am in relationship to my depression. That's helpful. So getting rid of diagnosis isn't the issue. It's building a different kind of way of thinking about them. But to say this person is a schizophrenic is really a signifying them. It's really making them as a thing and deciding who they are, and it's an act of power. I figured you out. And a person experiences that way too. They experience it as this person's controlling my of me.

Katie: Right. They're identifying me and there's so much more to me than that.

Dr. Ross: Yeah. It is the last thing I should be defined by. My brokenness should be the last thing I should be defined by. So that's where that stuff gets difficult, and that's happening a lot. And also just treatments are becoming pat and internal family systems stuff. I'm really not interested in finding my fireman. I don't have, it's these parts they talk about, I don't know. I understand it. I appreciate its approach. It actually has some of the most beautiful elements of psychotherapy in it. But people are trading in this stuff now where they're saying, this is my part, this is this part. It becomes kind of this way of identifying everything that I don't think is helpful. Freud invented free association just about the same year that Buddy Bolin invented jazz in Mississippi. And psychotherapy is an act of improvisation. It's a kind of improvisational art. It has the same demands of improvisation, which is I'm responsible to respond well to the person and to hear what they're saying and then modifying my response to their response. It's always a dialogue. That's what it was built to be. It's a kind of improv in which one person's suffering, one person's trying not to get gratified by the experience and to be there present for the person in an improvisational way. These other things aren't pure profit at all here to figure out where you rest in regard to this illness and how these little techniques I learned can fix you. It’s the opposite of that. Yeah,

Katie: Yeah. It's so interesting because people are really trying to systematize treatment in some ways and using evidence-based approaches, and all of that's a, it's a great idea and it's great in theory, but at the end of the day, we're humans and we're unique. And even though we have the same diagnosis, what'll help me is going to be unique and different based off of what'll help somebody else. And that's what continues this kind of challenge, I think, in this field.

Dr. Ross: Yeah. Yeah. Remarkably, remarkably, there's a really interesting research done by her last name's Michaels, I believe. And she was a marketing person who became, I think Psychoanalytically trained. And so she knew how to do consumer research. They did this massive consumer research on why people go to therapy, and it came out. They're looking for someone to hear them. It didn't come out, I want to fix myself. The consumers know more about what should be going on than what's being provided. There's this massive gap because what they want is I want a warm person who will hear what's going on for me. I want a witness to my experience. That's what people are saying they're going for. So there's a sadness there that we're not trained anymore to provide it, partly because to train somebody in some therapy takes very little to train somebody in how to be present in a way that helps a person recover, takes the person working on themselves. The training is how do I become, become the instrument of this, not what technique to learn. That's why supervision was once the main way to train somebody. Now you take a course for a year and get certified in this… 

Katie: And you train, put an acronym at the end of your name, and you're off and running. So these are gaps that it's like we're not seeing in front of our own face sometimes.

Dr. Ross: Yeah, absolutely. Yeah. 

Katie: That’s so wild. So I'm going to ask you another question, and I think I know the answer to this, but I want you to expand more on it, which is, do you think that a mental health challenge or a diagnosis is something that someone can overcome with time, with the right treatment, with community integration? Or are these some of these symptoms, maybe they're hearing voices, something that they'll always struggle with, or maybe not, struggle isn't the right word, but always maybe have, and they just need to learn to work with that within themselves, within their culture or their society that they're around. What are your thoughts on that?

Dr. Ross: I think that there are some experiences that are quite painful that a person may need to learn to live with, maybe even build a relationship with where they understand also where it's been good for them. Maybe see it as something that came out of their own self-love and self coping. But that's something that they live with. But there's also a lot of psychiatric events that are much more transient than the literature claims literature. It's classic for a person in med school to get trained that one third of schizophrenia is transient. They don't live that way though. Psychiatrists don't live that way. They live as if a hundred percent. So we already know for the research, one third of schizophrenia is transient, but the only research that's been done on people that come off of their medications, this is from this book by Robert Whitaker called Anatomy of An Epidemic.

Katie: I read that book. It's one of my favorites.

Dr. Ross: Yeah. Yes. You know this. Yeah. So this story that the only research that proves that people need to stay in their meds is people who took themselves off their meds without their psychiatrist knowing, which means they didn't titrate their meds, they didn't get any help with their meds.

Katie: Cold cut Turkey. Yeah,

Dr. Ross: Exactly. Yes, exactly. You know this. Yeah. Yeah. So we're still living in that world, that one third, we're not even reaching the one third in how people think about schizophrenia. If we reach that, that'd be beautiful if it was just accepted. What you're taught in medical school is true, but I believe it's much bigger than that one third, that so many of these experiences are transient. If we treated them that way, people would do better. And especially with schizophrenia, what we do to people who have this experience is pros psychosis. So psychosis is typically spurred by stress and isolation, and then something else that's going on for the person. I'm not saying it's just those things.

And our treatment for psychosis is the first person you meet is typically a cop. Then you're on an ER for maybe 48 hours or longer, often strapped to a stretcher.

Katie: Wow.

Dr. Ross: Then you get the treatment. And treatment is a hospital unit. Yeah. Well, that's really pro psychosis. That's pro stress and isolation.

Katie: Yeah, it's very traumatizing too.

Dr. Ross: Yeah, exactly. Yeah. So what would that be like? How much more transient will we be creating it if we had models of care that were about, how do we help you get to a place of calm?

How do we make you feel like you're connected to people more? And finally, that's what they're doing with first break work. They're finally doing these models. It's about how do we kind of make you feel like a part of things? This is the first break, work now on psychosis. It's irritating for us social workers because doctors are taking credit for this new idea that it's important for people to feel integrated in the world. Like some brilliant idea that we never tried to mention to them earlier.

Katie: They've increasing us for decades. Yeah,

Dr. Ross: Yeah. But we're going to keep our mouth shut because we're really happy they're looking that direction because it's good. It's good that finally we're seeing that the social elements are vitally important. Schizophrenia is this experience of profound estrangement from the world, and our treatment estranges them. So why would we not want to make the moment when they have this break, a welcoming event instead of an ostracizing one?

Katie: Right, right. Yeah. I find it so interesting, and I've always wanted to kind of analyze how people with schizophrenia, their treatment leaves them in 20 years here in first world countries here in the States versus in other countries that are more community first, where they're not shoving medication down them first. They're really trying to integrate them with their local culture. And I just think that the results are going to be interesting to really see. Sometimes some ways we think we know so much more, but in other ways, we kind of miss the boat on some of these social factors here in our first world independent, first kind of countries.

Dr. Ross: Yeah. My program is one of the first programs in the United States to be trained in this thing called Open dialogue, which is about how do you have conversations with people who are having these experiences that actually calm them down and make them feel heard and things like that. It comes from Finland and this hospital in Finland, Carra Putus Hospital, the community around there, the psycho psychosis rates dropped often without a lot of medication, often without any medication. They started taking the people off medication. That's actually where anatomy of an epidemic ends. He shows up at that hospital, and that model is about how do I help this person feel connected to things?

Katie: Absolutely. Well, you mentioned that you, or before the show, we talked about how you're also an author. So tell me a little bit more about some of your books, what you have going on, how people can maybe learn more from your teachings.

Dr. Ross: So I'm working on the fourth book now, and that book's on holding, which is the experience of being the same experience you have from being physically held, but psychologically, I think it's the most profound and important thing that we do for each other is the sense I'm being held in another person's head, person's I'm held in my community. And I think when that crumbles, you end up with people looking for ways to be held in extreme ways, like possibly wanting an authoritarian leader, that kind of thing. And then the previous book before that is my favorite book right now, which is, it's called Purple Crayons. It uses herd and purple crayon to talk about the seriousness of play. That play is actually this very serious element that often people don't want us to engage in, but being playful is what you and I are doing right now.

It's about being in dialogue with the world, being connected to the world in a way where you feel like you have some say over that experience. So it's not silliness. And then most of our conversation today was reflecting the stuff I'm doing. I did for a book called How We Change, which talks about my research on Fear of Hope too. And then before that is a book on the way in which people who go in and out of the hospital are often engaged in what I call patient careers, that the ways in which they get in the hospital is because they're in a career crisis and the career crisis is that their career as a patient is being threatened and how to help them through that, because it's not a pleasant thing to believe that you had a victory by getting into the hospital. So how do we not criticize those people? Because they're often criticized, but how do we understand their experience and how do we help them out of it?

Katie: Right, exactly. Very cool. I love that. So where are your programs again?

Dr. Ross: Boston, Los Angeles, and New York City.

Katie: Okay, great. So yeah, for any of our listeners who are in those areas, if they want to get in touch with your programs or learn more about your programs, what would be a good way to get in contact?

Dr. Ross: ellenhorn.com.

Katie: Okay,

Dr. Ross: Fabulous.

Katie: Awesome. Well, thank you so much for your time today. This was really enlightening. I love your perspective. It's so cool that you've also read Anatomy, even Epidemic. I have not met very many people who've read that book.

So yeah, just keep on fighting the Good Fight. We need more experts and leaders in this space who are having these conversations, frankly. So with that, I appreciate your time and for everyone listening today, we're live every first and third Wednesday of the month. And you can see all our episodes at katierosewaechter.com or Spotify, apple, wherever you listen to your podcasts. And with that, we will see you in a couple weeks and have a good one, everyone. Bye.