I have been a child psychiatrist for more than 20 years. I’ve worked in the city, in the suburbs, and in rural settings. I’ve seen patients in teaching hospitals and I’ve run a busy private practice. In all that time, I have never seen psychiatric suffering as pervasive and intractable as I have over the last 18 months. The lack of real change in our nation’s child and adolescent mental health infrastructure has fostered a pernicious and pervasive defeatism among patients and clinicians alike.
At its worst, this is manifest as a boarding crisis for young people with mental illnesses, who are simply being warehoused in general hospitals. Allowing children and adolescents to languish for days, and often weeks, while waiting in general hospitals for a psychiatric bed to become available is a recipe for patients and caregivers to lose all hope that things will ever improve.
This hopelessness is a major feature of the current emergency. It might even be the major feature. Things will not get better unless the approach to it can effectively remedy this deeply engrained pessimism. Mental health stigma has been impressively diminished. Now it’s time to overcome the ugly defeatism that fosters the ongoing inertia in mental health care.
The vast majority of children and teens who are admitted to general hospitals for suicidal thoughts and behaviors do not, in fact, harm themselves while they are waiting for psychiatric placement. Policy makers may misconstrue this lack of self-harm as decreasing the urgency for authentic structural change in mental health care. It ought to be obvious that simply boarding young people in regular hospital beds cannot be the primary solution. Patients, their families, their doctors and their communities become increasingly hopeless as the mental health crisis continues without any real change.
The worst part of this hopelessness is that it becomes, in and of itself, a kind of nihilistic contagion. By that I mean a malignant, contagious negativism that co-opts the willingness to change. Nihilism, after all, means nothingness. This contagion foments the sensation that nothing helpful can be done.
Here is how this psychological contagion spreads:
A child with mental health problems comes to a general hospital and the family quickly learns there are simply no — or very few — treatment options. The tools available for psychiatric care in general hospitals are extremely limited, and no beds are available for specialized psychological help. People wait days, sometimes weeks, for appropriate treatment to become available. They are too sick to go home, but are in the wrong kind of hospital for what they need most. When children and teens become stuck like this, they internalize the message that their suffering is not planned for or taken seriously. They compare this lack of action to the immediacy of treating other illnesses. When they contract strep throat, they receive quick and effective treatment. If they need surgery, they get it. But things are different for serious mental illness. Hopelessness takes hold and spreads through communities and across social media platforms.
This contagion of hopelessness can take on many forms. Sometimes patients and their families simply give up. When combined with incompletely treated mental illness, this translates to more lethal attempts at suicide. No note is left, no warning given, and children either die or come nearer to dying at their own hands. These tragic events tend to come to light when a suicide triggers a local or social media headline that, in turn, leads to an increase in others who harm themselves. This phenomenon, called the suicide contagion effect, has been well documented for decades.
Some youths internalize the hopelessness. Adolescents especially embrace the role of being “the kid with a problem that no one cares about,” a consequence of poor resource availability and the normal drive toward identity that is characteristic of coming of age. In other words, these young people identify first and foremost as being sick with an intractable societal problem. This feeling is then continually reinforced and perpetuated by the inadequacies of the health care system. And as they share their views with others, the hopelessness spreads.
I think that things have been so bad for so long that no one remembers that the U.S. health care system, and indeed our entire culture, can do better. This nihilism reminds me of a virus because it gets under individuals’ emotional skin. People feel sick with inaction and feverish with frustration. These feelings, just like a virus, spread quickly and aggressively through entire communities.
But it is important to remember that the same frustrations existed for a very long time with regard to the stigma associated with mental illness. Indeed, the strides made against this bias in many ways can explain today’s predicament. More people are willing to look for help, but the mental health care system hasn’t caught up with those increased numbers.
The first step toward fixing the boarding crisis for children and adolescents with mental health problems is to acknowledge, unequivocally, that this mess is fixable. It will take financial resources and creative inspiration and genuine structural change. It will certainly take bipartisan support. And it will be costly. Still, it is possible.
Refusing to act is immoral. It is also emotionally and financially devastating for everyone. A spirit of optimism is more essential than ever. This is no time to surrender hope. The country’s children and adolescents deserve better.
Steven C. Schlozman is a staff child psychiatrist at Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire, and associate professor of psychiatry at the Geisel School of Medicine at Dartmouth.
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