The writer is co-author of “Interpersonal Psychoanalytic Theory for the 21st Century: Evolving Self,” published by Lexington Books. She has been a practicing psychotherapist since 1968.
Until the 1970s, psychiatric hospitals in the U.S. were huge, much like prisons, warehousing thousands of people diagnosed as “insane.” There was little therapy, besides electro and insulin shock, with a low “cure” rate. Many people went in, but few came out to integrate productively with society. There were exceptions, hospitals that employed talk therapy and therapeutic environments with a trained and sensitive staff, but these were few and far between and were usually only available to those who could afford them.
In the 1970s, there was an attempt to break up the huge mental hospitals, supposedly to end the nightmare conditions, where people gradually lost any ability to function socially and, incidentally, cost a lot of money to house and feed. Atrocities that occurred at large state hospitals started to be exposed, the brutality and severe neglect finally on display. The process of discharge also became much easier with the advent of psychotropic drugs that, for the most part, controlled violent or “bizarre” behavior and made it easier for patients to live in the community.
Psychiatrists tended to hospitalize people for shorter periods of time and, in fact, to not hospitalize at all, but to rely on medication to calm symptoms. The psychiatrists, who were able to prescribe the medication, would then refer patients to nonmedical workers, like social workers or psychologists, who had the task of finding resources for them, such as a place to live, ongoing psychotherapy and vocational training.
But there was still a problem. The community mental health facilities failed to grow at a pace fast enough to support all the people emptied from large mental hospitals. Neighborhood clinics were too small, and caseloads of mental health workers became too large. Drugs weren’t always effective, and families couldn’t manage people, who, for example, sometimes attacked them, exposed themselves sexually in public or threatened suicide.
Caseload ratios could go as high as 150 patients to one therapist. The classic 50-minute session became 45 minutes and eventually 15 to 30 minutes, on a biweekly or monthly basis, as there were not enough therapists to accommodate the large number of people seeking treatment. This information comes from verbal reports by patients and mental health workers and in comments by social workers on a subreddit for the social work community, “r/socialwork.”
Psychiatrists, who were medical doctors and dispensers of medication, were pushed primarily into prescribing medication and not doing therapy. Therapy goals with patients became oriented to getting a diagnosis, so that the psychiatrist would prescribe a medication that fit that diagnosis. Then the psychiatrist would send the person to a mental health worker — a social worker, psychologist, a psychiatric nurse or a hastily trained “lay analyst,” who provided counseling and readjustment into society. But the goals of therapy morphed primarily into getting the patient to take their medication. This has meant big profits for Big Pharma.
These conditions continue today. In fact, people who display psychiatric problems, particularly if they are people of color, often are arrested, rather than hospitalized, or even shot if people call for police intervention in a psychiatric emergency. This has resulted in people experiencing an emotional crisis swelling the ranks of the prison population.
The mentally ill prisoner population
In prison, mentally ill people continue to remain untreated and are instead punished for what the police and prison guards treat as dangerous behavior. In prison, they often don’t even get their medication. The prison authorities use solitary confinement and other punishments that increase the person’s agitation and add to their despair.
Sometimes prisoners fight back against these increasingly brutal conditions. Here is one example reporting a support demonstration in Workers World newspaper:
“One prisoner, who identified himself as a Black man, spoke anonymously for fear of retaliation, stating: ‘This is a jail, not a place of healing or a place of care. We are subjected to trauma daily here. I want us to be clear on this point.’ The incarcerated speaker ended by thanking everyone who attended the protest, ‘I cannot express in words how very grateful I am for your assembling out here in order to demand that this county provide care not death.’”
Demonstrations like the one described above have occurred all over the United States for many years.
In summary, mental health care in the United States is disconnected from the network of social relationships in U.S. society. There is increasing reliance on pharmaceuticals and the development of a complex network of diagnostic categories. The availability of mental health counseling has markedly decreased in relation to the demand for it.
Mental health workers have very few resources to help their patients reintegrate with the surrounding culture. Prisons are replacing mental hospitals, and mental illness has been increasingly criminalized, particularly for people of color and poor people in general. The use of police to respond to mental health emergencies has increased the incidence of mental health crises ending in death, especially for the poorest and most oppressed people.
Socialist Cuba’s humane approach to mental health
The most up-to-date information about mental health care in Cuba comes from three trips, sponsored by the American Psychological Association, taken in 2013 and 2014 and reported on in the APA publication, the APA Monitor, in June 2015 by Rebecca Clay. It should be noted that these trips occurred during the Obama administration, when there was a thaw in relations between the U.S. and Cuba, which ended with the U.S. administration of Donald Trump. Since then it has been difficult to find accurate and detailed observations of psychiatric facilities in Cuba.
Sandra Soca Lozano, who is both a pediatric psycho-oncologist and a psychology professor at the University of Havana, was the guide for their trips. According to her, the health care system has several levels. The first is the primary care available in the consultorio, which Soca describes as a kind of “medical house.” Staffed by specialists in internal or family medicine, obstetrics and gynecology, pediatrics and psychology, each consultorio serves a neighborhood or small community of 1,200 to 2,500 people.
Each neighborhood has a CDR, or Committee in Defense of the Revolution, which coordinates with the consultorios and follows all the households as well.
Larger facilities, called polyclinics, offer more specialized equipment and care, including psychological care. The next level of care consists of hospitals, which includes psychiatric facilities. In addition, there are research institutes for specific medical specialties, which also offer medical assistance to the general population.
The most important concept underlying mental health services in Cuba is the strength of the relationship between mental health care and Cuban society as a whole. Mental health care is completely integrated into Cuban society. The orientation of health care in general is preventive, through education and frequent contact, so that potential health problems are spotted early before they become serious. Psychologists and other mental health workers are included.
Teams make regular visits to people in their sector, focusing especially on high-risk groups, such as children from birth to four years old, the elderly, people with diabetes and people with high blood pressure — all as part of an exercise of preventive medicine.
Mental health part of medical care
Psychologists are utilized in all other aspects of medicine. In the onco-hematology ward of the pediatric hospital where Dr. Soca works, for example, she routinely checks on all patients, monitoring for depression, anxiety and other problems, and prepares patients and families for diagnoses and medical interventions.
Consultations between psychologists and physicians go both ways, Soca adds. For patients with physical health problems, psychologists help educate physicians about psychological and other factors that can affect such conditions as diabetes and hypertension.
Mental health training for psychologists includes therapy during epidemics and other natural disasters; how to relate to addiction, sexual exploitation, gender and sexual identity; and new ideas developed from the recently passed Cuban Family Code; and how this is all integrated with the concept of community participation in the promotion of mental health.
Psychological training for therapy providers includes courses in psychology and society, psycho-ballet, psychoanalysis, group modalities, psychodrama, historical cultural studies, sexual identity and diversity, youth and sports.
Psychotherapy also includes forms of traditional therapies practiced by large sectors of Cuban people but formerly dismissed as “superstition.” These therapies are now being integrated into treatment modalities. Above all, treatment is always focused on the person’s strengths and oriented to finding solutions.
In a more long-term hospital setting, one of the most important forms of therapy in Cuba is occupational therapy, which in Cuba means that every patient must be engaged in some form of work or activity in a group context. The hospital provides a living arrangement where patients can gradually find a role in society through engagement in work that contributes in some way. There are a wide variety of activities available to each patient. Reintegration into society begins immediately.
In summarizing this comparison, it is easy to see how U.S. mental health care fails to achieve solutions for patients in mental crisis and how Cuba, even with the suffocating U.S. blockade imposed on it, can achieve successful reintegration of mental patients into productive and satisfying roles in society.
When the goal is promoting corporate profits, as in the capitalist U.S., the needs of the patients are irrelevant. If people do not create profits, they are deemed worthless. On the other hand, if the goal is to prioritize patients’ needs, as in socialist Cuba, it is possible to discover those needs and satisfy them within the context of the larger society.
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