Interview with Judith Krauss, Master of Silliman College
Judith B. Krauss, MSN, RN, FAAN is a Professor of Nursing at Yale University and Silliman College’s Master. She was the Founding Editor of Archives of Psychiatric Nursing, a practice, research and policy journal, and served as editor for 20 years. Her work focuses on health and mental health policy with a particular emphasis on vulnerable populations.
Your area in health care focuses on those with persistent and serious mental disorders. What do you think should be the goal of treatment providers when serving those with these serious illnesses?
We’ve made huge strides in understanding the neurobiology and genetics of serious disorders. In the years that I was most active in the field, my co-author Ann Slavinsky and I wrote the first book in psychiatric nursing about care of this population in the early 1980s. Back then there was what was known as the community mental health movement, and we were discharging large numbers of people from long-term care from psychiatric hospitals; many […] had been in those hospitals for years, if not decades. We finally had figured out that pulling them out of their communities and sending them off to upgraded asylums was not a good way to treat them. I’ve watched us progress from having very few tools to the development of many psychopharmacological tools. However, I […] think the pendulum has swung too far in the direction of relying nearly exclusively on psychopharmacological interventions with very little relevant talk therapy. People who have suffered a long time with the more serious disorders have all sorts of needs that aren’t directly related to their symptoms: they often need help managing everyday social interactions, help redefining their life and work goals, and they need health professionals working with them who understand the recovery model. Many health professionals of my generation either overtly or covertly don’t believe recovery is possible for some people and that tends to bias the way they engage in treatment. Most of my career has been about […] working with vulnerable populations, primarily those with serious and persistent disorders and defining ways in which the treatments embrace a relationship with that person. This recognizes a patient as a person, not a diagnosis, and understands that treatment needs to be as broadly conceived as possible and in some instances understands that people further along in a recovery process may be the best person, from a peer point of view, to work with recovering patients.
Since mental health illnesses are often difficult to diagnose, what measures could be taken to legitimize them?
That’s a very tough question. Really what you’re asking is how can we eradicate stigma. There is a whole set of diagnostic measures that rely on real-time data that we collect from patients. There are five core health professions: psychiatrists, psychologists, social workers, psychiatric mental health nurses, and marriage and family counselors. Psychiatry, nursing, and psychology have overlapping diagnostic training. There is a huge document that is a diagnostic taxonomy that helps us sort out symptoms that we collect from people. There are some tests now [that] people can do such as CAT scans and genetic tests [...] There are now many more hard science ways to confirm a diagnosis. We also now know a whole lot more about symptoms sets – if a patient has a group of symptoms, one can conclude that the patient is suffering from a certain disorder such as manic depression rather than some other diagnosis. We do have more refined ways for diagnosing, but still the real problem is the stigma associated with psychiatric disorders. I see it as a Master – when students suffer from psychiatric disorder it tends to be a far more traumatic experience than a broken leg, a diabetes diagnosis, or even cancer.
When I started my career(I came to Yale in 1970 [to] do my graduate work), there was a movement in mental health in general where we were discharging a lot of people with mental health disorders. Now, those same people who have psychiatric disorders are kept in hospitals for two to three days and [then] put […] back on the street. If we don’t attend to the wider constellation of needs they have, many of them end up homeless and on the street. Our current healthcare system is becoming very fragmented, and the people most likely to get lost in this system are people with serious and persistent mental health disorders, people who are poor, and people who come from ethnic backgrounds where mentally ill people have been discriminated against.
What would a system with mental health parity entail?
We’ve made strides in mental health parity, but there are too many loopholes. True mental health parity would mean we treat mental disorders in the same way we treat diabetes, cancer, and broken legs. If someone has insurance, it covers mental health illnesses to the same extent it covers physical illnesses. When I was at the IOM [Institute of Medicine] looking at safety net issues and when I wrote the monograph for the American Nurses Association for mental health parity, everyone was afraid that if we provided true parity in coverage, people who didn’t have diagnosable disorders would be using up valuable psychotherapy time. That was and is an unsupportable fear in parity. There are ways to control this in all of health care. We now do have laws that say that if an employer provides insurance for physical health it must include mental health coverage. However, there still are limits on it. Ironically, the limits are put in place to prevent people who don’t need it from overusing it but it constrains people who really do need it. In the long run, it costs the system.
How do you think mental health treatment systems can address the overconsumption of resources posed by cosmetic pharmacology, especially when there are so many people suffering from truly disabling mental illnesses?
There are key areas along a life continuum that we can look at. I think we need to look at end-of-life care. In general, the largest amount of health care resources is used at the tail end of our lives, in our 80s and 90s. I think, as a society, we should say there is a point after which these should be considered electives. We should be looking at our health care choices and the cost of these choices. This would leave more money for people with serious disorders. We also need to shift, as a society, […towards] wellness care and away from illness care. Right now, the United States is all about illness care. We’ve always been reluctant as a society and group of health care professionals to hold people accountable for their health. We need to change […the] care system itself. We need to reorient as a society towards prevention and staying well. How does this help people with schizophrenia? It may or may not, but a lot of mental illnesses are triggered by environmental factors, and many of these can be prevented. If we broadened our workforce and were thoughtful about who is assigned which health professional based on what presenting needs the patient has, we could do a lot more with the system we have. Also, in America we need to accept that even though health care should be a right, we should still be accountable to pay for it. I think we need to build in sticks and carrots for the individual seeking care and build incentives for prevention.
Where do you think the biggest resistance to health care policy change comes from?
Right now, change in health care policy certainly is a political issue. I am simply disgusted with our two-party system and the fact that nothing can get done. Right now, the main incentive in our government is to discredit the other party. This basically means no policy changes can be made. This is certainly one area of resistance. The American people themselves aren’t sure about health care. The public doesn’t have the will for the broad changes that need to be made, understanding that there will be winners and losers – there will be some gain that an individual will make and some things that an individual will need to give up or pay for. Health care reform is a daunting task […] Thirdly, we have an employer-based health care system. In the United States, the main source of health care insurance is our employer. We also have a government insurance system that covers people who are unemployed or older. Big business and small business have different interests in health care. So, a reform that might be palatable for big business is generally not palatable for small business. Managed care is based on payment by volume rather than fee per service. Big business can handle this but it’s harder for small business. The resistance comes from the people who pay (employers), the insurers themselves, the across-the-aisle two-party system, and Joe and Jane America who may not want any change at all.