INTERVIEW

Pursuing better health and better healthcare

Janet Silversmith, JD, CEO of the Minnesota Medical Association

For those who may be less familiar with the MMA, what can you tell us about the organization?

With more than 11,000 individual members across the state – from all specialties, all practice types, and representing diverse opinions and viewpoints – the MMA is the state’s oldest and largest professional association for physicians and physicians-in-training. Among our most distinguishing attributes is our advocacy voice on behalf of medicine – the profession of medicine – not the interests of medical practices, facilities, or other particular business interests.

My favorite fun fact about the MMA is that it is five years older than the State of Minnesota, having been founded in 1853. Although the original purpose of the organization remains intact after 169 years – to improve health and healthcare for all Minnesotans – our current work is focused on the most significant issues and challenges of today.

What can you tell us about ways the MMA has responded to COVID?

From day one, we had two primary goals in mind – to help shape the state’s pandemic response with the perspectives and experiences of practicing physicians, and to help keep physicians (member or not) across the state informed and connected. I’m really proud of the countless ways in which we did – and continue to – accomplish those goals.

There were two very specific things that we did during the pandemic that were extremely well received – we quantified and documented the financial impact of the pandemic on physicians and physician practices, and we launched a public education campaign called Practice Good Health. Through the Practice Good Health campaign, we deliberately leveraged the public’s trust and confidence in physicians and amplified accurate, current, and evidence-based information on how Minnesotans could best protect themselves from the virus, including direct appeals from physicians to mask up and to get vaccinated.

And, like everyone else, the pandemic forced us to do our work in new ways. For us, that meant new ways of reaching and engaging physicians. Some of those ideas, such as our noontime virtual Physician Forums, have been so incredibly popular that we plan to continue them beyond the pandemic.

Physicians make a “...” difference every day in the lives of the patients they see. “...”

Aside from the pandemic-related work, what can you tell us about some of the changes that have occurred at the MMA since you started as CEO?

I assumed the CEO role in January 2018, which after the past two years, feels like a very long time ago. I think the most important change in that time has been a new and very clear strategic plan that leverages our unique expertise and defines clear outcomes we want to achieve. Our mission, which I believe in so strongly, is to make Minnesota the healthiest state and the best place to practice medicine. The MMA’s elected physician leadership, through our strategic plan, has fully embraced the dual aims of that mission with specific work to improve community and public health, as well as specific work to improve the environment – both socio-economic and practice setting – in which physicians care for patients.

We’ve also made some internal changes that I’m proud of, such as adding more diversity to our board and elected leadership.

As some of the traditional ways that members used to get involved have changed, and in recognition of how busy our members are, we needed more flexible options for their involvement. One way we responded was with the launch, in mid-2020, of The Pulse, which is a new online policy development and membership polling tool. This tool, which is incredibly easy for members to use, has significantly expanded the number and diversity of members who influence and inform our policy development and advocacy work. In fact, given its ease of use and accessibility, other state medical associations are now working to adopt the tool for their own use.

To remain relevant, every association, including MMA, must embrace change as a constant. As a result, we work very hard to listen to our members, and our prospective members, to understand their needs, interests and concerns, and to involve them directly in our work.

The MMA is involved in a lot of advocacy work, including legislative advocacy. Please tell us about some of your advocacy priorities.

Yes, advocacy is one of our essential functions. Consistent with our mission, our advocacy has both a public health focus and a medical practice focus. Legislatively, we are involved in a significant number of issues as we work to protect the patient-physician relationship from outside interference, promote public health, and improve access to high-quality, safe, and affordable care.

In 2022, we actively pursued three legislative proposals. One of these proposals, included in the House omnibus health and human services bill, would protect patients who are taking medications for chronic conditions from having their medications and coverage changed mid-year by their health plan. Many health plans and pharmacy benefit managers (PBMs) make frequent changes

to their formularies or preferred drug lists as they chase rebates or discounts. These frequent changes mean that many patients who are doing well on one drug must switch to a different medication that may or may not work as well for them. For some, that means additional office visits or lab tests; for others, it means delays or gaps in their treatment or, worse, emergency room visits, hospitalization, or other complications. The legislation would continue to allow health plans and PBMs to make formulary changes to manage drug costs but would protect any patients already on such medications from having to switch to another medication until the end of their insurance contract year.

Another 2022 proposal would begin the process of creating an electronic repository for completed POLST (Provider Orders for Life Sustaining Treatment) forms. Many patients with serious, life-limiting conditions have worked with their healthcare team to translate their treatment goals and preferences to a POLST form, which is a medical order. But because it is a paper form, EMS and other healthcare professionals are often unable to easily find the form when called to a patient’s home or when a patient is admitted to a facility. As a result, patients’ preferences may not be followed. An easily accessible POLST repository, as is available in several other states, would help ensure that patients’ wishes are honored.

The final proposal we advanced in 2022 builds on Minnesota’s long-time commitment to patient safety. Patients who experience an adverse event still often complain that they encounter a deny and defend atmosphere and do not receive a complete explanation of what happened. Our legislative proposal would facilitate adoption of the evidencebased CANDOR (Communication and Optimal Resolution) model in Minnesota by protecting from discovery communications and documents that are created for purposes of resolving an adverse event with a patient. The CANDOR process involves immediate disclosure of an adverse event to a patient and/or their family and includes communication with the patient throughout the entire investigation and resolution. The CANDOR process has been shown to improve patient safety, better support healthcare team members involved in the event, and decrease malpractice claims.

I also want to note that our advocacy work extends well beyond the legislature. For example, we work on the regulatory side with state agencies, directly with public and private health plans/ payers, with community-based organizations. We are also active in legal advocacy, primarily through the filing of amicus briefs. Some of the recent legal cases we have been involved in include support for the state’s eviction moratorium during the pandemic (Heights Apartments, LLC and Walnut Trails, LLLP v. Tim Walz and Keith Ellison) and support for the City of Edina’s ordinance prohibiting the sale of flavored tobacco products (RJ Reynolds v. City of Edina). Also, in partnership with the Minnesota Hospital Association, we cautioned that mental healthcare in Minnesota could be negatively impacted if physicians and other mental health providers can be held legally responsible for the behavior of any patient for whom they prescribe medications containing a black box warning (David Smits, as Trustee for the Next of Kin for Brian Short, et al., v. Park Nicollet Health Services, et al).

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The MMA Foundation is an important part of the MMA. What can you tell us about the foundation and its work?

The MMA Foundation, under the executive leadership of Kristen Gloege, is a critical partner in helping us make Minnesota the healthiest state. Founded in 1958, the MMA Foundation was originally focused on providing low-cost loans to medical students. While the Foundation is still committed to supporting future physicians, today much of the direct funding to students occurs via project-based scholarships to support student research or community service activities. The Foundation recently expanded its statewide reach by launching two grant programs to fund physician-led projects aimed at improving community health or advancing health equity. We also maintain an active physician volunteerism program to help safety net clinics and other non-profit organizations expand access to care. I’m also proud of the Foundation’s work to fund physician-led, suicide prevention training in medical groups across the state. Additional initiatives are in the works for 2022.

What is the MMA doing to address physician burnout?

This is such a critical issue that, for many, has been made worse over the course of the pandemic. Importantly, our work to reduce burnout and support professional satisfaction and well-being recognizes that the factors driving burnout are broad. This is not a simple problem of physicians not being resilient enough or one that can be solved with free yoga classes or pizza. Rather, the factors driving burnout are individual, practice/organizational, and external (e.g., socioeconomic, regulatory, cultural). As a result, we are working in all those areas.

To support individual well-being, the MMA offers educational resources and programming, including our annual Reclaim the Joy of Medicine conference. To help address practice/ organizational sources of burnout, we have convened wellness leaders and champions from practices and systems across the state to share strategies, lessons, and challenges, and to identify how, together, we can accelerate this work statewide. Finally, our advocacy work addresses some of the biggest external sources of burnout, such as prior authorization.

Health equity initiatives have become part of every health care organization. What are some of the ways the MMA is responding to these issues?

Improved health equity is a key strategic outcome for the MMA, and we have invested new resources to reflect that commitment. We have also been very intentional about defining a focus for our work that leverages our strengths as a medical association. Our three current streams of work are focused on: diversifying the physician workforce; addressing the social drivers of health, particularly housing; changing the culture of medicine – inside the MMA and externally – to mitigate structural racism and implicit bias.

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Do you have patients with trouble using their phone due to a hearing loss, speech or physical disability?

Contact the Telephone Equipment Distribution Program for easier ways to use the phone. Phone: 800-657-3663 Email: dhs.dhhsd@state.mn.us Website: mn.gov/deaf-hard-of-hearing

The Telephone Equipment Distribution Program is funded through the Department of Commerce – Telecommunications Access Minnesota (TAM) and administered by the Minnesota Department of Human Services.

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3Health Capability from cover

understand what health means in a wider and fuller context. As a health care delivery system, from a regional, national and global perspective, it is necessary for us to rethink how we approach health care.

What is Health Capability?

Health capability is the ability to be healthy; it is a power to perform with the potential for achieving desired ends, as was cited in an article entitled “Health Capability: Conceptualization and Operationalization” by Prah Ruger in a 2010 edition of American Journal of Public Health. It entails individual aptitude and is a cradle to grave concept which requires life-long abilities and aptitudes that enable optimal health. Health capabilities are key strengths resulting from individual and societal commitment of human, financial and physical resources with the goal of helping people thrive.

There are inherent differences in individual health capabilities and by looking at them empirically we can begin to understand why personal skills and health benefits alone are not enough to be as healthy as possible and that a narrow biomedical model for disease is also insufficient. We can see that even people in the best external conditions can still have poor health.

The health capability model captures the dynamic, interactive, multidimensionality of both health and flourishing. It considers the overlap of biology and genetic predispositions with macro, social, political and economic environments, public health, health care systems and intermediate social contexts such as economic status and political empowerment. (chart)

Health capability employs a more flexible approach to health care than linear approaches that are limited to one-to-one associations among variables. This kind of reductionist approach looks at basic relationships first and then the sum of the principal subcomponents, producing a data set that can be difficult to interpret and to comprehensively represent a person’s lived experience. Health capability accounts for both internal and external factors on an individual level and allows for contemporaneous multiple relationships among factors. This overlapping feature offers a nuanced, sequentially interactive, dynamic and multidimensional understanding of individual ability to be healthy. It reveals heterogeneity in the influence of irreducibly social experiences.

A valuable element of this model is how, over time, it allows multisectional, longitudinal, inter-sectorial and institutional analysis and design. It considers heterogeneous relations among individual and societal level variables (e.g., income, education, race and racism, sexism and gender discrimination, hetero-normativity and LGBTQIA2S+). By measuring and using a different construct we can better address problems around lack of information on the direct health impact of external factors. Rather than drawing inferences about individual health based on group or macro level characteristics (e.g., race, gender, or socioeconomic status), health capability incorporates external factors into the individual level and considers impacts of the individual on society.

The Health Capability Profile

To understand this more clearly, we have created a health capability profile comprised of 15 different health capabilities which encompass 49 separate health functionings and agencies. The goal is for each and every person to reach their highest health potential, their full health capability. The profile provides a full picture of a person’s lived experience and of their journey toward reaching their healthiest and most flourishing potential. The capabilities are internal and external and include: • Internal Capability 1: Health Status and Health Functioning – Your state of health.

• Internal Capability 2: Health Knowledge – Knowing about your health and knowing how to be healthy. • Internal Capability 3: Health-seeking Skills and Beliefs, Selfefficacy – Believing in yourself and your health. • Internal Capability 4: Health Values and Goals – Valuing health. • Internal Capability 5: Self-governance and Self-management and

Perceived Self-governance and Management to Achieve Health

Outcomes – Managing your health, achieving health from within. • Internal Capability 6: Effective Health Decision-Making –

Making good decisions in health. • Internal Capability 7: Intrinsic Motivation – Being self-motivated toward health.

• Internal Capability 8: Positive Expectations – Having positive expectations about one’s health and flourishing. • External Capability 9: Social Norms – Cultures of health and expected behaviors in society. • External Capability 10: Social Networks and Social Capital for

Achieving Positive Health Outcomes – Connecting to others for health.

• External Capability 11: Group Membership Influences – Health norms of your social groups. • External Capability 12: Material Circumstances – Having material circumstances that support health. • External Capability 13: Economic, Political, and

Social Security – General feelings of security. • External Capability 14: Utilization and

Access to Health Services – Receiving health care when needed.

• External Capability 15: Enabling Public

Health and Health Care Systems –

Effectiveness of health systems.

Examples

To look at the structured thinking behind these capabilities let’s examine #4, an internal capability, Health Values and Goals. Within this capability is a sense of agency and valuing setting health-related goals such as managing cholesterol levels. It includes valuing lifestyle choices such as moderate vs. excessive drinking and the ability to recognize and counter damaging social norms. Health values and goals is the internal capability of valuing ones health, including health-related goals and health-promoting behaviors. Examples of this are regular exercise, a healthy diet, and an active lifestyle. Importantly, it also includes the ability to recognize and counter social norms that undermine the value of health and to persist in these values despite negative social messaging.

When we adapt these capabilities, encourage them in ourselves, in others and in our communities, it is important to consider three questions: (1) why are they important, (2) what do they look like and (3) how do I do it. Valuing health is important because we live in a world of finite resources, including one’s own resources of time, attention, and energy. Health will be compromised if it is not prioritized and understood to be central to a good life. We can recognize when a person sets these priorities through their words and actions. They

Health capability presents will speak positively about health and work to a dynamic, flexible, detailed, explicitly counter social norms that damage multi-dimensional topology. health. How they structure their daily schedules, their free time, their plans and both short and long term priorities will also speak to the value they place on health. It is important to note that health values and goals are continuously developed. Part of how one values health is through asking some core questions such as: why is my health important to me? What resources am I committing to my health? What goals can I set to become healthier? How might I change some of my unhealthy lifestyle habits and what social norms may be detracting from my health? To continue this analysis, let’s look at an external capability, #9, Social Norms. Health Capability to page 144

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Social norms may vary based on culture however they are to be evidencebased and scientifically valid.

They include the extent to which health seeking behaviors and healthseeking skills are viewed favorably (e.g., minimal use of alcohol, abstinence from drugs, safe sex practices) or unfavorably (e.g., alcohol abuse, obesity within the family). They also include the extent to which healthy behaviors are adopted by the majority or minority of the individual’s societal population and by whom within this population. They include the extent to which discrimination or anti-discrimination is the dominant social norm and how this impacts the provision of health care and public health services. How do these factors lead to disparities in access? How do social norms ameliorate disparities in health care access and how do they provide decisional latitude or power in familial contexts that are conducive to each person’s health agency?

Social norms are particularly important as an external capability because they shape our beliefs and actions. They provide guidance to what is acceptable, normal, valuable and important, and to what is expected in order to belong to society. Living in society that encourages and sustains people to be active agents of their own health is a critical capability. When society includes positive scientifically accurate norms such as childhood vaccines,

influenza immunizations, respectful and anti-discriminatory expectations about behavior and empathy and care towards helping its members thrive, everyone benefits. It is important that health care and public health providers ensure that underserved populations and communities are not put at risk by power imbalances in either the parent-child relationship or by unscientific beliefs of the parents. We can develop the health capability of social norms with the promotion of positive public moral norms through individuals as well as institutions Health capability incorporates such as the media, academia, governmental external factors into the agencies, and popular culture. individual level. Applying the Health Capability Profile Practical applications of the health capability profile consist in a three-step process. The first step is to adapt the profile to the health condition and to the setting under consideration. The second step is to document the adapted profile through both quantitative and qualitative data collection. Surveys are created that incorporate response from all stakeholders of the health care process, including nurses, physicians, community resource centers, and patients themselves. The analysis of the data draws from a synergistic approach that adopts a position of equal value for quantitative and qualitative data creating mixed methods results. This analysis uses 1-100 health capability scores and the creation of flow diagrams at the individual level. In utilizing these steps and creating a data analysis plan, there are multiple layers. First, the individual level

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through the documentation of individual health capability profiles. Profiles are unique to each individual at the point in time they are created. They offer multi-level analysis and show strengths vs. vulnerabilities at a glance, as well as highly granular data. Individual profiles are intrinsically dynamic and nuanced and allow for optimal circumstances (e.g., absence of symptoms) as well as enabling conditions. Profiles can reveal multiple causes and thereby better describe people’s complex experiences. In the analysis plan, there is also a cross cutting level of investigating each of the 15 health capabilities and a regional/ community level.

The final step in applying the profile is to employ the results to foster policy change and improved health capability for all. Indeed, the individual profiles identify cumulative and heterogeneous effects, which help address equity concerns. They also showcase underlying vulnerabilities and illustrate how to build collective resilience. Finally, they highlight strengths and present positive examples on how to achieve optimal health capability. Health capabilities can be promoted in many ways, including community-wide sensitization that improves knowledge and fosters evidence-based social norms around health care, or through motivational interviews and community outreach, which can be implemented alongside institutional reform in a more comprehensive approach to health policy.

Case Studies

As discussed, health capability is a flexible model and can be applied to each and every situation that involves health. The health capability profile is adapted to specific conditions and settings, for example, in addressing chronic hepatitis B virus in rural Senegal. Details about the methodology of this study are available in an article entitled “Applying the Health Capability Profile to Empirically Study Chronic Hepatitis B in Rural Senegal: A Social Justice Mixed-Methods Study Protocol.” by Coste, Marion, Mohammed A. Badji, Aldiouma Diallo, Marion Mora, Sylvie Boyer, and Jennifer J. Prah that is in press for 2022 publication in the protocol journal BMJ Open.

Conclusions

To summarize, health capability presents a dynamic, flexible, detailed, multi-dimensional topology. It includes individual factors, socio-cultural aspects and institutional features that together create health and flourishing. It accounts for and captures interactions among individuals and their environment. It can be applied to empirical studies using a mixed methods social justice design. Its implementation science identifies gaps among observed health capabilities and the optimal health capability level. The health capability profile demonstrates how individuals and societies can work together for each and every person to reach their highest potential, their full health capability and ultimately flourishing.

Jennifer J. Prah, PhD, MSC, MA, MSL is Amartya Senior Professor of

Health Equity, Economics and Policy, at the University of Pennsylvania’s School of Social Policy and Practice and the Perelman School of Medicine. She is also the founder and director of the Health Equity and Policy Lab (HEPL).

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3Improving Psychiatric Health from cover

quickly sat down and struggled to get his bearings straight. “What the hell is happening?” he thought to himself. Befuddled, his colleagues immediately went to his aid, confused by the sudden physical change. Bryan struggled to breathe, and his hands began to tingle. A colleague called 911,and he was rushed to the local hospital with suspicion of a heart attack.

Shawna was finishing the second trimester of her junior year. She was getting top marks in her classes and recently began a part-time job at the local grocery store. She saw a therapist regularly for anxiety and depression and spent a lot of time online with social media. Her parents were helping her plan college visits this spring, with aspirations of being an artist. During dinner with her parents one evening, Shawna was unusually quiet. She unexpectedly became tearful and told her parents she hated her life and had been cyberbullied online by several classmates. She began to sob uncontrollably, and her sadness turned into anger and shouting about feeling controlled. She slammed the door to her room and told her parents she wanted to die. She was not responding to her parents’ pleas to talk through her locked bedroom door. They burst through, finding her hiding under her covers. She shouted to her parents, “Leave me alone! I took some pills so I don’t have to be here anymore!”

As a young adult embarking in a new chapter in life, Eugene was feeling good about his mental health. As a teenager he struggled with a learning disability and experienced traumatic racial discrimination. His longstanding therapist helped him through many challenging periods in his life. Now, upon starting a new job, he learned that his therapist was out-of-network with his insurance plan. Unable to afford the costs, he sought a new in-network therapist, but was unable to find a provider who shared the same race or ethnicity. Eugene began experiencing intense anxiety at work, and his new therapist failed to grasp the impact of his past life experiences. He lacked rapport with this new supervisor, who criticized his performance. His self-worth plummeted as he quit his job and subsequently dropped the new therapist. Eugene was able to rejoin his parent’s insurance plan and started a new job search.

Mental illness is real, common and treatable. Bryan and Shawna are experiencing extreme symptoms of some of the most common illnesses, anxiety and depression. Eugene is among the majority of BIPOC individuals who have been a target of racism in the US and are twice as likely to experience severe emotional distress than White Americans. Access to acute care, like Bryan and Shawna need, or specialized care, such as a BIPOC provider who specializes in trauma for Eugene, is increasingly difficult. All three are dealing with common and preventable challenges of our psychiatric health system.

National polls show 42% of teens are concerned about becoming severely depressed.

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Bryan and Shawna represent nearly 14% of emergency department (ED) visits that are a result of a psychiatric crisis. Bryan is among the one-third of US adults who will experience a panic attack in their lifetime. On his way to the hospital, he will likely get an EKG in the ambulance. He will receive additional diagnostic testing upon arrival to the ED to rule out lifethreatening medical conditions like cardiac arrest. He can expect being in the ED anywhere from 4 to 12 hours for observation and receive an antianxiety PRN medication for stabilization. Bryan will likely be discharged from the ED with a short supply of a medication with instructions to follow-up with a psychiatrist and psychotherapist. There is a 50% chance that Bryan will follow-through with those referrals. Shawna represents nearly a third of teens that report cyberbullying. Recent national polls show 42% of teens are concerned about becoming severely depressed, and nearly 1 in 10 teens who have attempted suicide. She will likely be boarded in the ED for anywhere from a day to a week while awaiting admission to a psychiatric bed for treatment, which will likely require a transfer to a different facility. There is a 40% chance she will be discharged while waiting for that much needed bed.

In both cases, their crises were very real and unfortunately common. Their symptoms are both highly treatable with the correct intervention. Most importantly, we can create systems that can prevent these crises from occurring, crises that not only stress our health care systems, but also create inherent trauma for the patients and family members involved. Both M Health and Centracare have opened special units for these cases called EmPATH (emergency psychiatric assessment, treatment and healing).

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Unlike traditional ED’s which need to manage a plethora of medical crises, the EmPATH units are designed to be low stimulation and have access to mental health professionals to help with calming and stabilization.

ED’s have become the most common entry point for those in crisis, and that number has grown by nearly 40% in the last 20 years, even more for youth. Nationally, this represents an estimated 50,000 mental health-related emergency room visits per day, or over 600 per day across Minnesota. The most alarming trends in recent years are the increase in suicidal thoughts or attempts and drug/chemical overdoses. While Bryan and Shawna’s cases are not uncommon, additional factors such as medical comorbidities, cultural differences, social determinants, family dynamics and parental issues (for youth) can quickly complicate situations–requiring more than just psychiatric treatment, but intensive social intervention and support. This is also where our health systems have a propensity to apply the empirical allopathic approach to medical care that often fails to address complex biopsycho-social-spiritual elements. If Eugene should experience a crisis, the providers involved will need to be sensitive to his cultural background, past experiences with the US health care system and his previous trauma. While the psychosomatic symptoms of anxiety can easily be confused with a variety of medical conditions, providers must connect with patients in authentically compassionate ways to uncover often hidden mental health concerns.

According to the CDC, nearly 2.3% of all ED visits result in a transfer, yet in the case of a psychiatric crisis, independent studies have shown it is closer to 15%. The odds of a psychiatric patient waiting for care in an ED is nearly five times greater than for any other health condition–oftentimes resulting in days in an ED awaiting the appropriate care for their condition. The wait time to access psychiatric care can range from several hours to several days. This situation, known as “boarding,” has become increasingly common as a shortage of psychiatric care providers and barriers to accessing care have become amplified. A robust study conducted in 2014 showed that over 40% of psychiatric ED visits resulted in discharge, presumably without any meaningful treatment other than ad hoc medication administration and outpatient referrals, which are rarely followed up upon.

History of Psychiatric Hospitals

Throughout the United States in the late-1800’s, expansive federal psychiatric hospitals were built to create safety and sanctuary for those with severe mental illnesses. These hospitals, commonly known as insane asylums, provided care across the nation to nearly 560,000 individuals. These institutions often sprawled over half a million square feet and cared for nearly two thousand at a time. A psychiatrist named Thomas Kirkbride was the founder of moral treatment aiming to provide comfort and healing to patients who may have previously been considered untreatable. Some patients with conditions such as mania or bipolar disorder (though it was not called that at the time) were able to receive treatment for weeks to months at a time before returning to their communities, typically with increased family or social support. Many other patients with more severe conditions, like schizophrenia, developmental disabilities or autism, often became indefinite residents who built longstanding relationships and even

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