the Selling of Sanity

Teenagers crowd toward the door, girls dressed in trendy black, boys trying to look older than their acne, all talking and laughing at Once. They could be any freshman homeroom class going bowling. Except one of them wears houseshoes. And all of them wear the yellow plastic wristbands that identify them as patients of a psychiatric hospital.

At the front desk, a mother, slightly disheveled in slacks and a sweatshirt, clutches her overflowing bag to her side and takes a pen in her hand. Just as quickly, she puts down the pen and rakes her free hand through tangled hair. “Now, what is this for?” she asks, desperation obvious in her voice and on her face. A hospital employee tells her it’s just a routine form she must sign to make it clear that if her daughter harms herself or anyone else while she is hospitalized, Charter Hospital of Dallas is not responsible.

Another woman wearing a smart red suit waits among the small crowd forming in the busy reception area. She’s come to pick up her daughter. “Will you bring her down to me?” she asks the receptionist. No, the mother will have to go to the room since her daughter is being released against recommendations.

Now two preschoolers burst through double doors into the waiting area, book bags in tow. It’s time for them to go home from psychiatric day care.

This is any day at Charter Hospital, but it could be any day at any of the other sixty-plus private psychiatric hospitals, treatment centers, and treatment programs that are springing up in the area like office buildings once did, A recent issue of the local Treatment Centers Magazine listed almost fifty pages full of Dallas-area hospital and treatment center programs-in tiny type. The Chamber of Commerce may not trumpet it, but these private hospitals are the new moneymakers, our current boom industry. Just open your newspaper or this magazine, flip on the television or the radio, wait a few minutes, and hear the new healers compete for your business. In each advertising spot, a friendly, concerned voice hawks a universal message: send them to us, they beckon, your tired, your stressed, your depressed. They promise help for the depressed older woman. Help for the substance abusers. Help for the husband who won’t mow the grass. And, increasingly, help for the child who is miserable, misbehaving, or, some fear, just misunderstood.

For many reasons, children and adolescents make up the most promising-and worrisome-segment of the market in this booming brain business. Those who are skeptical of for-profit psychiatric hospitals say that young people are being targeted because there are simply more resources available to pay for children-Mom’s insurance. Dad’s insurance, and when that runs out, perhaps sympathetic grandparents on both sides. Defenders of the for-profits say they’re answering a crying need: the number of hospital beds for youth is growing because that population was underserved for many years, because our youth are more troubled in this dysfunctional world we live in, and because early help for a child with mental problems can increase the potential for progress.

While there are well-meaning and responsible advocates on both sides of the debate, anyone looking for psychiatric help should be aware: this is a branch of medicine that is developing like no other before it, in a largely unregulated atmosphere in which the techniques used to sell soap and new cars are now being used to sell sanity, or one definition of it. Marcia B. Bryan, executive director of the Dallas County Mental Health and Mental Retardation Center, sums it up with a blunt comparison: “Consumers must realize,” she says, “that they are buying a service that is not as intensively reviewed as going to the grocery and buying meat.”



Babes in Psychland

The red flag went up for family court judge Dee Miller when she learned that all three Children Of One divorced couple had been hospitalized in a psychiatric treatment center-but not due to the ravages of divorce. In this case, the father had taken his twin five-year-olds and their seven-year-old sibling boating. The boat sprung a leak, and the dad and kids waded to shore. The situation was not life-threatening and might have been dismissed by many people. But the couple’s oldest child had been killed years before in a boating accident. When the father look the kids home, he told his ex-wife what had happened.

“The mother, understandably perhaps, overreacted, got the kids upset, and took them all to a psychiatrist,” Miller says. The psychiatrist, affiliated with a for-profit hospital, admitted all of the children on the spot.

Miller acknowledges that “it’s scary to go against a professional,” but in this case, she decided to seek another opinion. She had the children evaluated by a psychiatrist from Southwestern Medical School who found nothing wrong with the younger twins. He said the older child might have needed some outpatient therapy, but not because of the boating accident. Rather, he was still grieving for the older brother and upset about his parents’ divorce.

Though cost was not the main issue here, the family-and its insurance company-were paying phenomenal fees: $824 a day per child for the basic costs, not including physicians’ charges. With many insurance companies putting a $15,000 lifetime cap on in-patient psychiatric services, many kids are found well enough to be discharged in three to four weeks, just about the time they run out of benefits. In fact, many treatment programs are designed around the medical benefits. One Dallas-area psychiatric hospital places three bits of information on the front cover of a patient’s chart: name, date of birth, and a dollar figure indicating how much insurance is left.

Knowing all this, judges like Miller have come to believe that second opinions are important-especially when hospitalization is the issue, where the judge, the parents, and the physician are all-powerful. Children under sixteen years of age have no real voice in their own hospitalization: they are simply signed in by a parent, managing conservator, or other legal guardian. Miller’s concern is shared by other family court judges-among them Frances Harris and Theo Bedard-who are beginning to see a worrisome new trend: the hospitalization of preschool children who may not need such intensive treatment-and may be harmed by it.

Judge Harris has made second opinions routine in her court when it comes to hospitalizing children and youth for psychiatric care. “If you are going to be responsible when you usurp the parents’ role, you need a second opinion. No one is perfect,” Harris says.

Recently, Judge Theo Bedard ordered a second opinion when a Ph.D. affiliated with a for-profit psychiatric hospital recommended hospitalization for a three-and-a-half-year-old. “I had a psychiatrist at Southwestern Medical School see the child and he had a different idea,” Bedard says. The little boy was upset by his parents’ divorce and continuing problems with visitation, and Bedard says the psychiatrist recommended counseling, but felt that, at most, the child should be placed temporarily with another family member rather than in the foreign environment of a hospital.

With more and more parents in Dallas picking up the phone and calling the numbers that flash across their television screens, family court judges find themselves in the role of mental health watchdogs. Pointing to the plethora of television, radio, and print ads offering help, the judges worry that in the best-case scenario, desperate parents with too many problems of their own are being sucked in by the well-packaged promises from psychiatric hospitals. At worst, they fear that parents who have the insurance are dumping kids into the system as an easy out and that doctors who are also in business to make money are not going to refuse a paying patient. Judge Miller stresses that parents should get second opinions when deciding whether to admit their children to a hospital, and says they should “treat this as you would any other illness.”

A burgeoning number of medical experts are afraid that in society’s growing reliance on therapeutic solutions, we are beginning to label any family or child with a problem “dysfunctional.” Ron Anderson, CEO of Parkland Memorial Hospital, is one doctor who fears the trend he calls “the medicalization of emotion, where sadness is labeled depression and people who get angry are sick.”

According to MH/MR’s Bryan, the ad campaigns for the hospitals “set up the expectation that teenage behavior in the normal range of growth and adjustment can be fixed easily.”

Bryan is not alone in her fear that many teenagers are being hospitalized for behavior that is part of “typical adolescent adjustment.” Substance abuse, increasingly a cause for treatment among both adolescents and adults, is not the issue here. Keith Lauerman, a former Piano teacher now attending law school, says he saw frequent cases of what he considered “adolescent mischief” being categorized by psychiatric treatment centers as “psychotic behavior.” At one point, Lauerman says, a sixth-grade teacher in Piano had eight students in the hospital at one time. The Dallas Independent School District reports a 510 percent increase in the number of hospitalized kids since 1985.

As is often the case in the mental health field, doctors sharply disagree about what constitutes inappropriate hospitalization, and the potential ill effects of such treatment. Dr. Douglas Puryear, director of psychiatric emergency services at Parkland Hospital, absolutely believes hospitalization can be damaging to children when it’s not needed. And Puryear thinks that more and more kids will be hurt as the aggressive marketing brings an inevitable increase in admissions.

“Hospitalization disrupts life. It creates an image of the person in both their family and community and leaves them with a stigma,” Puryear says. “For a time, there was a shortage of adolescent beds. There was a genuine need, but when private hospitals are advertising this hard and with such a sweeping net. I don’t know. I think the general community is concerned,” Puryear says. “The ads seem to be saying ’if your kid has lost his homework, put him in the hospital.’”

For-profit administrators dismiss claims of unnecessary admissions and argue that the ads have positive effects. Liam J. Mulvaney, administrator of Green Oaks psychiatric hospital, thinks advertising has served to educate the public about mental health and has helped to break down the stigma of “being in a psychiatric hospital.” Mulvaney, who has been in the business for nearly twenty years, says that when he used to mention what he did for a living at a cocktail party, people would fall silent. No more. Now, he says, they talk to him comfortably about all of the people they know who have been in treatment.

That type of talk is also common in the halls at local high schools and middle schools-another danger sign, say the critics of the for-profit boom. MH/MR’s Bryan grants that the ads have led to greater awareness of mental illness, but warns that teenagers are now twisting what was once a stigma into a status symbol . A stint on a psych ward-especially in the very expensive programs that can cost more than $5,000 a week-has become a cool thing to do, proof positive to peers of rebellion.

Given this shift in attitudes, the new “summer camps” that some treatment centers now market to kids should be all the rage. Summer Solutions, the camp program at Green Oaks, was created “for parents who know that summer, with its long hours of unstructured and unsuper-vised time, can mean trouble for kids,” according to a recent press release from the center. The program will offer sailing, scuba, swimming, horseback riding, and rock climbing in between therapy sessions.

Mulvaney, the Green Oaks administrator, admits that he is not always happy with the quality or the cost of the mega-marketing-’even my own.” Ads that are overly dramatic or hysterical, he says, are as distasteful to him as they can be to the public-especially ads that prey on children and distressed parents. And as a businessperson. Mulvaney says he dislikes the amount of money he has to spend on advertising.

“But the name of the game now is to make people aware,” he says. So he gets the Green Oaks name out there with the rest of them, banking on a good number of admissions from the secondary effect of ads the other guys paid for, too.

Asked about inappropriate or exploitative marketing schemes, mental health care professionals will mention the opening festivities for Charter Hospital of Dallas-Fort Worth in Grapevine. Last September, Charter used a costumed Batman and the grossly popular Teenage Mutant Ninja Turtles to draw potential customers. The first 500 children at the grand opening received free teddy bears. For-profits don’t like to talk about that PR stunt.

Jan A. Moppert, the new director of marketing for Charter Hospital of Dallas in Piano, says she tries to use tasteful ads and marketing approaches that show solutions and are primarily educational. A recent print ad, for example, featured nine questions for parents to ask before their child enters a treatment program. And, she adds, Charter’s conversion rate-the number of admissions compared with the total number of phone calls asking for help-averaged only 15 percent over the last six months.

Moppert’s not above using a well-known name to focus attention on Charter, but she insists that the personalities be appropriate for the event. Captain Kangaroo came to Charter Hospital of Dallas for the opening of its children’s wing, and Moppert has also called on the celebrity power of Thomas “Hollywood” Henderson. The ex-Dallas Cowboy’s struggles with substance abuse, she explains, give him a value and credibility that no cartoon character can possess.

Mulvaney and Moppert freely admit that public appearances by celebrities and steady advertising have led to more admissions of children. They maintain, however, that the marketing barrage has served to educate parents, making them more comfortable with psychiatric treatment.

“These kids used to go to reform school. Now they come to the hospital. I’d rather have them treated than end up in jail,” Mulvaney says. “There’s been a change-now we deal with problems in a therapeutic way rather than in a criminal way.”

The staunchest defenders of the for-profit revolution also point to some bleak realities that, they hint, many of their critics would rather not face. The critics may be finding it difficult to “break through denial,” says Moppert. Dr. Doyle I. Carson, psychiatrist-in-chief at Timberlawn Psychiatric Hospital, says that while the concept of hospitalizing children is disturbing to many, “it is often hard for people to realize the seriousness of illnesses some youngsters can have.”

In other words, just because the for-profits harp on a problem doesn’t mean it’s not a problem. “Every ninety minutes an American teenager cuts short a life that’s just begun. . .their own,” Brookhaven Psychiatric Pavilion warns in a print ad. It’s dramatic, but the fact is that suicide is now the nation’s second leading cause of death among adolescents. Some children, like some adults, do become suicidal-and psychotic, depressed, and dangerous to themselves and others. A child five years old was recently hospitalized in the Dallas area after killing a younger sibling.

Despite the realities of mental illness in little children, Mulvaney says it’s hard getting used to having the tiny ones around. “I see them and I wonder who has come to visit,” he says. Seven months ago, Green Oaks added a children’s program to its list of services. Now a swingset sits on the lawn where patients take a break from therapy. It’s not far from the swimming pool.



The High Cost of Happiness

After more than $30,000 worth of treatment and eighty days as an inpatient, the eight-year-old girl was discharged from a local psychiatric hospital. The problem was that she still wasn’t well. The girl’s father started asking some pointed questions about her expensive treatment. Just what had the hospital done to his little girl all of those weeks?

Most consumers are not savvy about the ins and outs of psychiatric treatment-especially for children. And this father was no exception. Tools like the “papoose board,” a restraining device some hospitals use on kids as more of a punitive than a therapeutic measure, sound like instruments of torture from the dark ages. And to the uninitiated, vague psychobabble like “community therapy” sounds like something needed by the Dallas City Council, not an eight-year-old.

This father’s search for answers began with the hospital, which declined to release details of his daughter’s treatment. Since the child had been signed in by his ex-wife, who was a managing conservator during their divorce, he then went to his family court judge for help, but still did not get the records.

Dallas County MH/MR’s Bryan understands this father’s frustrations. She says that private hospitals have often been slow at delivering medical records when patients have been transferred into the public sector. While the for-profits say privacy is the main issue in transfer of records. Bryan says that private hospitals “may not care to have the clinical review of other doctors.”

Private hospitals enjoy much more discretion and face much less accountability than public mental hospitals. To administer elec-troshock treatment, for example, a state psychiatric hospital would need approval from many sources, including the Texas MH/MR commissioner in Austin. Private hospitals use the treatment at their own discretion.

Like numerous other parents, the father of the eight-year-old was baffled by this type of autonomy, and so began one man’s attempt to hold a private hospital accountable. He wrote the attorney general. He wrote the mediation committee of the Dallas County Medical Society. He wrote the Health Facility Licensure and Certification Division of the Texas Department of Mental Health and Mental Retardation, which sent him to the Texas Department of Health Medicare office, which authorizes Medicare payments to private facilities. At the end of a tortuous trail through jargon and red tape, he found one of the reasons for his daughter’s plight: deregulation.

In Texas, the boom in private psychiatric hospitals-and the ads that tout their services-can be traced directly to the deregulation of health facilities, In the last five years, the number of private psychiatric hospitals in Texas has more than doubled, and the numbers are still growing. In Dallas, Timberlawn was for decades the only private psycniatric tacility in town, joined later by Baylor and Presbyterian and their private psychiatric services. Now the mega-chains like Charter, HCA, and CPC, along with myriad independents, vie for market share.

The Miracle Grow for this thriving garden of mental health care was applied in August of 1985 when the Sunset Commission retired the Health Facilities Commission. The HFC had regulated hospitals in Texas and issued “certificates of need” that required hospital owners to prove-and demonstrate they could meet-a definite need in the community before opening. When the sun set on certificates of need, entrepreneurs and speculators entered the business and money became a more important motive.

Getting a license to open a psych hospital is not a complicated process. The Texas Department of Mental Health and Mental Retardation oversees the licensing for private hospitals, but MH/MR doesn’t send out an army of inspectors, relying instead on the recommendations of the Joint Commission of Accreditation of Healthcare Organizations, a respected volunteer organization that sets industry standards. If a hospital passes muster with JCAHO, it pays a nominal yearly fee and is deemed to meet state requirements.

Just prior to deregulation, the federal government decided to reorganize Medicare payments by creating Diagnostic Related Groups that set limits for payment by diagnosis and reined in charges at general hospitals. Diagnosed with appendicitis, for example, Medicare would now pay a set fee. Psychiatric disorders, however, were exempt from that law. There are plans to phase them in later, but until that time psychiatric hospitals have a hand in the deep pocket of Medicare.

Psych hospitals already had a blank check with generous insurance policies, says Marilyn J. Gerald, vice president of clinical services for Managed Health Network Inc. Gerald’s company manages mental health benefits for corporate customers on a case-by-case basis, serving as an advocate for high-quality care and helping them to keep insurance costs under control.

Of course every hospital watches the bottom line, regardless of whether Uncle Sam considers it a for-profit, not-for-profit, or nonprofit institution when tax time comes. But some psychiatrists, mostly in the nonprofit sector, worry about overconcern with economics at for-profit institutions-especially when the doctor has a vested interest in a hospital’s financial status.

“This is a built-in conflict of interest.” says Dr. Kenneth Z. Altshuler, chairman of the department of psychiatry at The University of Texas Southwestern Medical School at Dallas, “And the dollars spent on advertising have no relation to the dollars spent on patient care.”

For-profits are getting used to defending themselves on this point. “Unless someone is working for a state agency,” says Frederic S. Goldstein, administrator of Charter Hospital of Dallas, “any hospital has to make a profit to survive.”

But prior to 1985, the Health Facilities Commission could monitor competition through its function of issuing certificates of need. Doctors like Altshuler worry about the current frenzied pace of growth. Now, with entrepreneurs in the business, it is the norm not the exception for psychiatric hospitals to hire not only a marketing whiz in-house, but also a public relations expert to help launch special events and new services. Hospitals hire recruiters to court and spark with school counselors, who can provide a wealth of referrals. Through round-table discussions, health fairs, and one-on-one meetings, hospital representatives make what are essentially sales calls to ensure that school counselors are fully familiar with their services.

Are the for-profit hospitals meeting a need? Or are they creating a need and a market through savvy sales techniques and Madison Avenue wizardry?

Both sides have numbers to support their position. Charter’s Goldstein and Moppert-a proven business team brought to Dallas from Shreveport-make the market sound nearly infinite. One in five children need psychiatric help, they say, and less than one in five who need it are getting it. The National Association of Private Psychiatric Hospitals offers these stats: eight million children in the United States under the age of eighteen are in need of mental health services. Three million of them are “seriously mentally ill.” The NAPPH says that at the most. 30 percent of those children are being served.

Faced with such numbers and a paying market, it’s no wonder business types whip out their calculators. But then there’s the flip side. Doctors like Park-land’s Anderson and Southwestern Medical School’s Altshuler believe that the paying market is now “overbedded”- thus the tremendous need to advertise. Marilyn Gerald of Managed Health Network backs up those beliefs. As part of her job, she extensively surveys psychiatric hospitals and treatment facilities. She believes that average occupancy rates are no more than 50 percent. Have the cash cows overgrazed the pasture?

“Something has got to give. The competition is very fierce and so we arrive at situations like this business of calling adolescents mentally ill when they are normally acting out,” Gerald says.

Altshuler thinks the situation has become dangerous: “We’ve reached a point where we need to protect people from the people who are supposed to be taking care of them.”

Consumers-like the man who is still trying to get his daughter’s records-have little power to complain or bring about reforms. It is the insurance companies, holding the purse strings, that can and do wield power with the hospitals. “Innovations” in the industry such as day hospitals and shorter hospital stays are a direct result of the insurance industry telling the for-profits to cut costs or else.

Managed Health Network’s Gerald is only one interested observer who predicts a coming shakeout in this crowded field. She predicts that more businesses will either try to cut costs and monitor their employees’ hospital stays by hiring companies like hers, or will cut benefits back severely because insurance companies will make them too expensive to carry.

“I think the main problem with for-profits,” says Altshuler, “is that there are so many of them. When the shakeout comes, their large advertising budgets will cause beds to be reduced or preserved not on the basis of quality, but on the basis of how well the companies get their message out.”

Altshuler certainly doesn’t look forward to that fallout. His realm, the public sector, is already overburdened with caring for an indigent population with severely limited funds. Only recently has Altshuler been able to solicit help from the for-profits, who seem to be saying give us your stressed, and your depressed, but not necessarily your poor. Last November, he coaxed twelve local hospitals, including several for-profits, into donating one bed each for emergency, short-term psychiatric care to the indigent. That’s a step in the right direction, but a small one: the indigent are grossly underserved, and Texas ranks forty-ninth, behind even Mississippi, in dollars spent on mental health.

But Green Oaks’ Liam Mulvaney says that private psychiatric hospitals pick up more slack than the general public realizes. He thinks his fellow for-profits do themselves an injustice by not publicizing the fact that they often let patients stay on after benefits have run out.

“We can’t give away as much as we’d like to,” Mulvaney says. “We are running a business that helps people. But we have to pay attention to the bottom line-we don’t get endowments or grants.”

“It’s still amazing,” says Marcia Bryan, “how many patients in private hospitals get well when the insurance runs out.”



THE WAITING ROOM AT CHARTER HOSPITAL IS EMPTY NOW, ONE mother having left a daughter, the other having taken one home.

It’s getting dark as the van full of teenagers returns to the hospital parking lot. The van stops at the front door where the kids pile out. less animated, their outside activity over for the day. They walk past flower beds planted with bright pansies that soften the entrance to the building. But no amount of landscaping can make this place look like home. When the doors lock behind these kids, they don’t have a key.

Soon after dinner, the parents will begin to arrive. Into the night they’ll meet with doctors and counselors, with their children, and with each other. They’ll talk about dysfunction and disorders and this therapeutic world we live in.

And tomorrow it will all begin again. The preschoolers arrive at 8:30 sharp.