New York City Voices interviewed Executive Deputy Commissioner of Mental Hygiene Lloyd Sederer, MD, at his office near City Hall during the summer. Dr. Sederer’s job is to oversee the quality of publicly funded mental health, addictions, mental retardation/developmental disorder and early intervention services for the City of New York. He has been described as the most powerful psychiatrist in New York City.
NYC Voices: What does [recovery from mental illness] mean to you—does it mean some level of societal integration, some level of productivity, ability to raise a family, hold a job, etc.?
Dr. Sederer: My job is to learn, appreciate and advocate for what are informed opinions, not just what Lloyd Sederer might think…I do believe in peoples’ strengths and I have hope that individuals can rebuild their lives whether they have mental illnesses or physical illnesses or have been traumatized.
NYC Voices: It is important for our readers to understand that the chief administrator who is responsible for the city’s mental hygiene…promotes recovery for the mentally ill.
Dr. Sederer: I have devoted my life to that. I have directly cared for and supervised the care of thousands of patients, I have run about every imaginable clinical mental health service, and I now have the privilege of overseeing public mental health in NYC. I have done all this because I believe in and am committed to recovery, to a life of meaning and contribution in the community, which is what I think we all want.
NYC Voices: What is Lloyd Sederer’s personal definition of recovery from mental illness?
Dr. Sederer: I believe in peoples’ capacity to rebuild their lives from mental illness. I also believe that recovery is more likely when there is a mutual effort that goes on between the person who has an illness and the clinicians involved in their care, as well as their family and loved ones. The more we are all collaborators, partners, in a person’s effort to move from illness to functioning and contribution, the more likely recovery will occur….
NYC Voices: …what is the vision or the dream or the hope or the destination, however you see it, for recovery for the mentally ill of New York City.
Dr. Sederer: In our 50th anniversary report, it says that people should have a life, a purpose and a home in the community…a job if they can work…most people want the same thing…a home, a life, people who love them and whom they love. They want to be purposefully engaged. They want to be able to wake up and feel some dignity about themselves and the way they are contributing to the community—that’s our understanding of what people want. That’s what recovery should lead to.
NYC Voices: What new programs and initiatives are the Department of Health and Mental Hygiene starting that work toward achieving this vision for recovery?
Dr. Sederer: One example is New York/New York Three, a housing initiative that is built on our belief that nobody gets better if they have a mental illness or drug problem unless they have safe and reliable housing. We worked with a great many stakeholders over an extended period of time and last fall we were instrumental in engineering an agreement between City and State for 9,000 units of supportive housing, which will almost double the existing supportive housing units in NYC. This housing initiative is one major contribution to recovery.
NYC Voices: That satisfies the need for shelter. What about the vision for a purposefully engaged life—how is the department working toward that?
Dr. Sederer: We support many different treatment and rehabilitation programs. Illness requires treatment, but treatment is not the same thing as rehabilitation or recovery, which is about rebuilding your life. Treatment is about managing your disease.
NYC Voices: Does rehabilitation mean vocational—
Dr. Sederer: Yes, that means being able to be more fully engaged in the community. That has to do with skills people need to function in the community, whether it is managing their money, managing social relations or being able to enter the workforce. We support programs that are specifically aimed at getting people jobs. We’ve been focused on a better understanding of what consumers want from these programs. What are their objectives?
NYC Voices: It’s been our experience who have been on the front lines serving people with mental illness as professionals as well as being mentally ill ourselves that we go through the services and many of us do not transform our lives despite our experience with these services. We remain disproportionately dependant on the services rather than gaining more independence from the skills we gained through the services such as socialization, vocational and other daily skills. What do you think are factors that can help services to lead mental health consumers to greater independence and less dependence upon them and that can help consumers achieve at least part of the vision for recovery that we talked about earlier?
Dr. Sederer: When it comes to any outcome in a person’s life—your life or my life—there are always a number of things that come together. If we have an illness, there is the impact of the biological part of the illness. And illnesses can vary; they can be mild, moderate or severe and some can be more severe than others. Then there is also the environment that somebody lives in. Are they fortunate enough to have a supportive, loving family? Did they grow up in poverty or did they grow up with a reliable source of income and know where their next meal was coming from? Were they housed? Did they have opportunities [to create their own lives]? Did they live in a dangerous neighborhood, or a safe one? Were they able to stay in school? These are a number of important environmental factors that influence the outcome of an illness, mental or physical. Then there is the quality of the care that they receive. We’re particularly concerned about the quality of care people receive because that is an important element. We ask, “Are they getting care?” If they are getting care, “Is it the right care, at the right time?”
NYC Voices: What does right care mean?
Dr. Sederer: There is a growing body of research and evidence that tells us which services are much more likely to achieve [results or goals for the consumer]. We need to support services that are known to be effective. So, for example, we’re very invested in case management and ACT teams for people who are not able to manage independently in the community. We also know that medications work. For some people, family psycho-education and family involvement works. We know that certain talking therapies are more effective than others with certain illnesses. The right care is the right intervention at the right time and for the right duration.
NYC Voices: Okay, when is the right time?
Dr. Sederer: For example, we want to be able to offer an ACT team to somebody when they’ve had many hospitalizations and emergency room visits. This pattern of service use is how we see someone communicating to us that something is not right in their life and that they are not getting the right care. Maybe what they need is an ACT team that may be the right treatment at the right time. At some point, hopefully, we’ll see a very different pattern of service usage, one that indicates that a person is on a path towards more stability and a better life. At that point, a less intensive service may be more appropriate for that person.
NYC Voices: There is research that shows how very young children can be diagnosed with schizophrenia. It’s already being done with bipolar disorder. Children are being medicated for bipolar in their teens or sometimes even younger. And that’s an intervention when the child who is having symptoms is taken to the clinic to receive a diagnosis and medication. Now with adults, an intervention requires a crucial need or a crisis—
Dr. Sederer: Let me interrupt you…your elaboration here gives us an opportunity to understand the differences between primary, secondary and tertiary prevention? Primary prevention is something that will keep somebody from getting sick in the first place. Secondary prevention is about providing something very early on when somebody is ill so that you either help them get completely better or you reduce the severity and duration of their illness. Tertiary prevention is about managing chronic illness.
NYC Voices: Are their any statistics that highlight the effectiveness or lack of effectiveness with the primary, secondary and tertiary preventions for mental illness in New York City?
Dr. Sederer: There is a lot of good evidence for the secondary and tertiary preventions.
NYC Voices: What does the evidence state?
(Dr. Sederer gets up to fetch a book from his library, returns to his chair and opens the book. He says that the book was produced by the American Psychiatric Association and that it describes various treatments for serious mental illness that have been shown to be effective. He points out the chapter on schizophrenia and says that it contains 85 pages and 581 references).
NYC Voices: I think it’s very important that we simplify the research studies to make it more accessible and readable to the general public [to whom you are accountable]. This is not a scientific [social] club. We’re really trying to help people. Very simply put, I think the general population can understand what percentage of the mentally ill on existing Medicaid or whatever rolls have benefited from secondary and tertiary preventions. Are 80% of them achieving our vision of recovery thanks to secondary preventions? Are 50% of them still completely dependent on the system despite tertiary preventions?
Dr. Sederer: We don’t have that kind of information overall. We know many things about different illnesses, and we know that with time, hope, persistence, good care and support, that people can improve their lives. For depression, for example, almost 80% of people can have significant improvement in their lives.
NYC Voices: Is the scientific community overcomplicating matters and not really solving the problem or are we headed in the right direction? When I say complicating, I mean huge volumes where the same amount of information could have been conveyed more simply and more directly without nearly as many pages.
Dr. Sederer: We know a lot more about how to help people today than we did ten or twenty years ago and we have a lot more to learn.
NYC Voices: Do you believe that the approach is too detailed and thus overcomplicating the quest for a solution?
Dr. Sederer: We are talking about peoples’ lives here. You would not be satisfied by an unscientific approach if you had breast or prostate or lung cancer, if you had heart disease, if you had diabetes—you wouldn’t be satisfied nor should you be satisfied to say, “Well, it’s too complicated all those studies about blood sugar, all those studies about cancer cells, and all those studies about the blood vessels—it’s much too complicated.” I’m saying to you, don’t stigmatize mental illness; it’s a real illness. It should have the same scientific rigor that cancer has, that diabetes has, that heart disease has.
NYC Voices: It’s my understanding from the scientific community that there is a hierarchy of the sciences…the hard sciences at the top: mathematics, physics, chemistry followed by biology…then within each science, there is a hierarchy. Close to the bottom of the biological sciences is psychiatry in terms of the respect that practitioners receive, of the study, of the significance [of this field]. You must be aware of this.
Dr. Sederer: I don’t agree with you. If you look at funding that has occurred in the past 10-15 years, we see a great deal of support for studying the basic science of the brain. Still, we need more. But I think this gets us away from our topic. What is your question?
NYC Voices: I’m saying that the field of psychiatry has a great many obstacles against it. And just like there is stigma against the mentally ill, an obstacle toward our recovery, there is stigma against psychiatry not only from society at large with movies like Hannibal the Cannibal [that portrayed] a psychiatrist [as a] serial killer, but also within the scientific community itself where [many scientists and professionals of] the “harder,” more mathematical and more established sciences [claim that psychiatry is still in its fragile infancy and may not survive the rigors of time].
Dr. Sederer: Which is why I said what I did in response to your question…I’ve spent a large part of my career saying that there is a science-base to help our understanding and treatment of mental illness. And I’m not going to be casual and say it is too complicated. We need to say that the science of mental health must be rigorous and we need to keep pushing for more rigorous science; not just for the biological sciences, but to learn what services work, and if people are getting what they want as results from the care provided. That’s our obligation; that’s our mandate; that’s my mandate.