Across the nation, approximately 1 in 5 Americans experiences some type of mental illness. Approximately 40% of those with schizophrenia and 51% of those with severe bipolar disorder go untreated. The consequences of non-treatment of mental illness are drastic and wide, ranging, from homelessness to incarceration to suicide. Treating these diseases is not easy – indeed, an estimate put the cost of schizophrenia treatment at $33 billion per year, on par with the $38 billion per year estimate of arthritis costs – but it is necessary.
While we have a growing public discourse as to the severity of mental illness and the importance of obtaining treatment, particularly amid the presidential election season and promises of changes to the American health care system, the consequences of non-treatment, we see precious little attention to the consequences of bad treatment. This is ironic given that physicians work to abide by the central principle of “do no harm.” And if it s true that there is no health without mental health, we must pay close attention to finding not simply cheap fixes and band-aid solutions, but constructive progress toward mental health stability and ultimately, thriving.
Universal Health Services (UHS), the provider of 20% of all inpatient behavioral health care in the United States, is emblematic of poor cookie cutter solutions to mental health that may ultimately do more harm than good. Founded in 1983, UHS is the largest provider of facility-based behavioral health care in the nation, operating 216 centers in 37 states, Washington DC, and Puerto Rico, the US Virgin Islands, as well as the United Kingdom. They claim to treat over 400,000 patients per year through a comprehensive range of inpatient and outpatient behavioral health services. Sounds great, right? Well, not quite.
Over the years, UHS has been caught in a number of scandals, from Medicare and Medicaid fraud to poor patient care. In March 2012, the organization and two of its subsidiaries paid $6.85 million to settle allegations that they were providing sub-standard care in Virginia and engaging in false claims under the False Claims Act. In August 2012, it settled for $4.25 a suit by parents alleging that they falsely billed for instruction of inpatient children and adolescents while actually just warehousing them. The institution has been alleged to have terminated whistleblowers across the nation, with employees raising issues such as patient neglect and sexual assaults against patients.
The UHS-owned behavioral health centers of Chicago have been caught in a number of scandals over the recent yeas, with the Illinois Department of Children and Family Services deciding in 2011 to no longer send children and adolescents to Hartrgrove Psychiatric Hospital and in 2013 not to send them to Garfield Park Hospital, due to hundreds of alleged violent attacks and sexual assaults against patients. Riveredge Hospital, also now barred from receiving patients through DCFS, has also had allegations of sexual assaults of patients, and in 2013 a patient there committed suicide by hanging herself on the unit. It is not difficult to conceive of how experiencing, or even witnessing, such events while seeking acute psychiatric care would be traumatizing (or re-traumatizing) to a patient already in a vulnerable state. These are not isolated incidents, but rather systemic problems that deserve not just piecemeal Department of Justice investigations into specific patient complaints, but rather a large-scale evaluation of the institution’s mismanagement of such a huge share of the nation’s mental health care services.
The Chicago metro area is hardly the only region in which UHS hospitals have come under heavy scrutiny and been found to gravely endanger patients. UHS's Timberlawn Mental Health System in Texas was determined to have practices that posed immediate jeopardy to the health and safety of its patients and failed to monitor adequately those who were suicidal. The Meadows Psychiatric Center in Pennsylvania was cited for failing to report a sexual assault on the unit. Fort Lauderdale Hospital in Florida failed to investigate numerous charges of patient abuse. The Hughes Center for Exceptional Children in Danville, Virginia has experienced numerous allegations of racial discrimination against staff members, hardly making for a therapeutic environment to which to send patients. The list goes on. Despite the national aspect of UHS's provision of mental health services, investigations into mental health care tend to be individualized, looking at state and not national reputations -- rare is the national review of mental health care provision. And what is perhaps most egregious about this patient mistreatment is that depression strikes at the very core of individuals' sense of self-worth and deservingness of human dignity, and the level of care (or lack thereof) afforded by this set of behavioral health centers only reinforces this cognitive distortion.
In a field of medicine known widely for being underfunded such that too few have access to needed services, Arbour Massachusetts Hospitals, affiliated with UHS, reported profits ranging from 15 to 32 percent, compared to single-digit profit margins by the nearby and top-ranked McLean Hospital. This is but one of many red flags that have been raised by this set of hospitals, also noted for having undertrained therapists, too few nurses given the number of patients, and fraudulently billing Medicaid for services provided by unqualified workers.
Many of those who are in the position of requiring inpatient psychiatric treatment have histories of assault and rape, the traumatic symptoms of which many of these centers purport to work to treat. Some research has been carried out to illustrate the dangers of retraumatization of prison inmates, many of whom already have histories of violence and/or sexual assault. Therapists working with victims of trauma work closely with patients to manage triggers and flashbacks given the risk that such patients face of retraumatization – and that is in a safe, clinical setting, not coming close to the levels of abuse reported in the UHS behavioral health centers.
The need for a large-scale investigation into UHS (mis)management is clear. The onerous system of complaint processing and litigation overwhelmingly benefits the upper echelon and “repeat players” (in this case, UHS) to the detriment of the more vulnerable populations (whether the children, the elderly, the homeless, or the mentally ill) who are ill-equipped to be effective advocates for themselves and who Galanter (1974) would characterize as the “have nots” who, rather than being intimately familiar with the legal system that they are navigating in order to assert their rights, are in stead “one-shotters” with greater stakes in the individual case. In the civil rights context, we see that while individual cases of discrimination may be brought piecemeal, there are greater interventions when there is found to be a “pattern or practice” of discrimination. Here, we have unequivocally a pattern or practice of mistreatment, and it is time to act accordingly.
We have seen many frightening images of bad mental health care depicted in films such as “One Flew Over the Cuckoo’s Next,” which arguably did more harm than good in the way of encouraging people to seek needed help for their mental health. While research has investigated the problems formerly associated with ECT, which originally carried more dangers, there have been fewer large-scale evaluations of substandard care’s impact on patients over time. It is not difficult to imagine that while a highly depressed person not in the care of a mental health professional might face a steady decline in functioning, their condition might spiral more rapidly out of control (and less predictably so) if on the wrong course of medication or subjected to traumatic experiences that stir up past traumas or grief, leading to outright regression.
There are a number of obstacles to obtaining good scientific research on “bad” psychiatric care. For starters, effectiveness of therapeutic treatments varies by patient, even with objectively good standards of care (responsible monitoring of symptoms, medication management, therapy). With good reason, Institutional Review Boards (IRBs) will not permit subjecting patients to poor psychiatric treatment conditions and measuring degrees of depression and anxiety pre- and post-treatment. However, finding mechanisms to longitudinally monitor treatment progress (or regression) when subjected to sub-standard conditions at UHS centers and elsewhere will be essential in gauge the deleterious effects of maintaining the operation of so-called patient care programs that may help some at the margins in a time of limited mental health care access, but appear to put many patients at risk. In the meantime, it is incumbent upon health care providers to think twice before referring patients for “care” in these hands.
While we have a growing public discourse as to the severity of mental illness and the importance of obtaining treatment, particularly amid the presidential election season and promises of changes to the American health care system, the consequences of non-treatment, we see precious little attention to the consequences of bad treatment. This is ironic given that physicians work to abide by the central principle of “do no harm.” And if it s true that there is no health without mental health, we must pay close attention to finding not simply cheap fixes and band-aid solutions, but constructive progress toward mental health stability and ultimately, thriving.
Universal Health Services (UHS), the provider of 20% of all inpatient behavioral health care in the United States, is emblematic of poor cookie cutter solutions to mental health that may ultimately do more harm than good. Founded in 1983, UHS is the largest provider of facility-based behavioral health care in the nation, operating 216 centers in 37 states, Washington DC, and Puerto Rico, the US Virgin Islands, as well as the United Kingdom. They claim to treat over 400,000 patients per year through a comprehensive range of inpatient and outpatient behavioral health services. Sounds great, right? Well, not quite.
Over the years, UHS has been caught in a number of scandals, from Medicare and Medicaid fraud to poor patient care. In March 2012, the organization and two of its subsidiaries paid $6.85 million to settle allegations that they were providing sub-standard care in Virginia and engaging in false claims under the False Claims Act. In August 2012, it settled for $4.25 a suit by parents alleging that they falsely billed for instruction of inpatient children and adolescents while actually just warehousing them. The institution has been alleged to have terminated whistleblowers across the nation, with employees raising issues such as patient neglect and sexual assaults against patients.
The UHS-owned behavioral health centers of Chicago have been caught in a number of scandals over the recent yeas, with the Illinois Department of Children and Family Services deciding in 2011 to no longer send children and adolescents to Hartrgrove Psychiatric Hospital and in 2013 not to send them to Garfield Park Hospital, due to hundreds of alleged violent attacks and sexual assaults against patients. Riveredge Hospital, also now barred from receiving patients through DCFS, has also had allegations of sexual assaults of patients, and in 2013 a patient there committed suicide by hanging herself on the unit. It is not difficult to conceive of how experiencing, or even witnessing, such events while seeking acute psychiatric care would be traumatizing (or re-traumatizing) to a patient already in a vulnerable state. These are not isolated incidents, but rather systemic problems that deserve not just piecemeal Department of Justice investigations into specific patient complaints, but rather a large-scale evaluation of the institution’s mismanagement of such a huge share of the nation’s mental health care services.
The Chicago metro area is hardly the only region in which UHS hospitals have come under heavy scrutiny and been found to gravely endanger patients. UHS's Timberlawn Mental Health System in Texas was determined to have practices that posed immediate jeopardy to the health and safety of its patients and failed to monitor adequately those who were suicidal. The Meadows Psychiatric Center in Pennsylvania was cited for failing to report a sexual assault on the unit. Fort Lauderdale Hospital in Florida failed to investigate numerous charges of patient abuse. The Hughes Center for Exceptional Children in Danville, Virginia has experienced numerous allegations of racial discrimination against staff members, hardly making for a therapeutic environment to which to send patients. The list goes on. Despite the national aspect of UHS's provision of mental health services, investigations into mental health care tend to be individualized, looking at state and not national reputations -- rare is the national review of mental health care provision. And what is perhaps most egregious about this patient mistreatment is that depression strikes at the very core of individuals' sense of self-worth and deservingness of human dignity, and the level of care (or lack thereof) afforded by this set of behavioral health centers only reinforces this cognitive distortion.
In a field of medicine known widely for being underfunded such that too few have access to needed services, Arbour Massachusetts Hospitals, affiliated with UHS, reported profits ranging from 15 to 32 percent, compared to single-digit profit margins by the nearby and top-ranked McLean Hospital. This is but one of many red flags that have been raised by this set of hospitals, also noted for having undertrained therapists, too few nurses given the number of patients, and fraudulently billing Medicaid for services provided by unqualified workers.
Many of those who are in the position of requiring inpatient psychiatric treatment have histories of assault and rape, the traumatic symptoms of which many of these centers purport to work to treat. Some research has been carried out to illustrate the dangers of retraumatization of prison inmates, many of whom already have histories of violence and/or sexual assault. Therapists working with victims of trauma work closely with patients to manage triggers and flashbacks given the risk that such patients face of retraumatization – and that is in a safe, clinical setting, not coming close to the levels of abuse reported in the UHS behavioral health centers.
The need for a large-scale investigation into UHS (mis)management is clear. The onerous system of complaint processing and litigation overwhelmingly benefits the upper echelon and “repeat players” (in this case, UHS) to the detriment of the more vulnerable populations (whether the children, the elderly, the homeless, or the mentally ill) who are ill-equipped to be effective advocates for themselves and who Galanter (1974) would characterize as the “have nots” who, rather than being intimately familiar with the legal system that they are navigating in order to assert their rights, are in stead “one-shotters” with greater stakes in the individual case. In the civil rights context, we see that while individual cases of discrimination may be brought piecemeal, there are greater interventions when there is found to be a “pattern or practice” of discrimination. Here, we have unequivocally a pattern or practice of mistreatment, and it is time to act accordingly.
We have seen many frightening images of bad mental health care depicted in films such as “One Flew Over the Cuckoo’s Next,” which arguably did more harm than good in the way of encouraging people to seek needed help for their mental health. While research has investigated the problems formerly associated with ECT, which originally carried more dangers, there have been fewer large-scale evaluations of substandard care’s impact on patients over time. It is not difficult to imagine that while a highly depressed person not in the care of a mental health professional might face a steady decline in functioning, their condition might spiral more rapidly out of control (and less predictably so) if on the wrong course of medication or subjected to traumatic experiences that stir up past traumas or grief, leading to outright regression.
There are a number of obstacles to obtaining good scientific research on “bad” psychiatric care. For starters, effectiveness of therapeutic treatments varies by patient, even with objectively good standards of care (responsible monitoring of symptoms, medication management, therapy). With good reason, Institutional Review Boards (IRBs) will not permit subjecting patients to poor psychiatric treatment conditions and measuring degrees of depression and anxiety pre- and post-treatment. However, finding mechanisms to longitudinally monitor treatment progress (or regression) when subjected to sub-standard conditions at UHS centers and elsewhere will be essential in gauge the deleterious effects of maintaining the operation of so-called patient care programs that may help some at the margins in a time of limited mental health care access, but appear to put many patients at risk. In the meantime, it is incumbent upon health care providers to think twice before referring patients for “care” in these hands.
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