Dec 30, 2012

Dear Vice-President Biden, Here’s what it takes to fix mental health

Vice-President Biden,

We've had from thirty to fifty years of mental health deinstitutionalization in America. Don’t listen to people who whine about the days of yore when we locked people away in big institutions. Presidents Kennedy and Carter were right. That should not happen again.

It’s time for Americans to adjust. As disorderly and chaotic as deinstitutionalization has been, every one of our civilian institutions has had enough time to figure out some basic strategies that work. The practices outlined below are well-documented and in place today, but on a hit-and-miss basis.

Access to treatment

The problem: People have difficulty accessing care and connecting with systems.

The solution: A single point of contact telephone number for a region or a county, connecting with multi-system resources for screening, assessment, and referral. A “no wrong door” mutual aid policy within healthcare and mental health systems that includes some basic protocols for data exchange. A tiered entry into care, with an emphasis on delivering the first appointment in a timely fashion.  Neighborhood health centers and public clinics with sufficient capacity for delivering assessments and delivering basic care for depression, anxiety, bipolar disorder and first-onset schizophrenia, plus family and caregiver education. More specialized care available promptly for more complex cases.  De-couple assessment systems from resource allocation systems. Do not change standardized assessments so that they “ration care.” Use mobile crisis teams to prevent escalation to the criminal justice system.


The problem: When we had big institutions, we underfunded them, but even then they were among the largest budget items for state government. As deinstitutionalization progressed, state governments kept funding the big hospitals for many years. For the most part, when these institutions closed, their former funding did not transfer to communities. And if it did, the money generally went for mental health treatment, not housing. Deinstitutionalized people found themselves with no way to access housing, because SSI, the primary source of income for people who never had substantial work histories, did not pay enough to cover the cost of market rate housing, and Medicaid, which pays for treatment, does not pay for housing.

The solution: Subsidized housing using housing dollars, plus case management services covered by Medicaid. “Housing First” policies work because they simply deliver a housing product, and, after thirty years, the mental health system has figured out how to keep people connected to mental health care. Small scale group homes also need enough supplemental funding to permit operators to deliver realistic levels of programming for people with a high burden of disability.


The problem: Unruly people with mental illness are clogging our courts and jails. The most difficult population has moved from mental hospitals to jails and prisons.

The solution: Diversion programs throughout the entire criminal justice pipeline. Pre-arrest solutions that give street level officers discretion to drop people off for mental health evaluation in lower-cost settings than emergency rooms or psychiatric hospitals. Jailhouse coordination with mental health agencies to provide early release of clients already in the system. Secure mental health facilities under criminal justice jurisdiction separate from local general population jails. Social workers available at all levels of the criminal justice system, including courtrooms and probation offices. Restorative justice programs that address the needs of crime victims and offenders, but allow a way out of imprisonment. Note: This works once the housing issue is fixed.

Police killings of people with mental illness

The problem: Too many people with mental illness end up dead after encounters with police.

The solution: Training every officer to identify mental illness and use appropriate tactics that de-escalate situations. Specialized units to respond to mental health calls. These practices must be incorporated into use of force policies and firearms training protocols. Many deaths of people with mental illness occur because these training protocols and policies were designed before the era of deinstitutionalization.

Violence and suicide connected with mental illness

The problem: People with mental illness become disconnected from treatment, stop taking medication, or use drugs or alcohol, and commit violent acts or suicide. People decompensate and become violent or suicidal without being connected with treatment.

The solution: Better communication, coordination and data exchange between all levels of the mental health, general health care, education, criminal justice, and court systems. More suicide prevention training within the general population. Risk management protocols that give greater weight to leaked signals of harmful intent. Sufficient secure healthcare facilities to handle immediate needs including mandatory minimum stays in step-down facilities for medication stabilization. Protocols within treatment systems that facilitate information sharing with caregivers or family members. Protocols that integrate college counseling centers with the community’s mental health provider system. Consider “safe harbor” provisions to permit and encourage information sharing under HIPAA and professional practice systems. Increase funding for substance abuse detox and treatment.

Suicide of armed forces members and military veterans

The problem: We are losing more soldiers to suicide than to other war wounds, and the high number of veteran suicides is simply tragic.

The solution: Increase the capacity of soldiers, families, churches, community groups and employers to detect problems as they are developing. This involves having face to face conversations and perhaps following a simple script, plus the willingness to ask about suicidal intent. You can find a script in my book Defying Mental Illness, and free suicide prevention training through the QPR Institute. Every community already has a front door for treatment.

That’s a start. I think we get the rest of the way with more emphasis on what ordinary citizens can do, starting with simply talking with each other, and recognizing that mental health and mental illness are not obscure and unfathomable or disgraceful, but legitimate topics for everyone. The experts are needed too, but many ordinary people with a little more training can do a lot to keep us safe. It takes an hour or two to train anyone on the basics of mental illness.

Let me know if you need some help rolling this out.

Best regards,


Dec 24, 2012

Strengths for the troubled

If you suffered a setback or a tragedy, how would you rebuild your life?

If rebuilding or recovering depended on your strengths, where would you look to find them?

A few years back, Victor Garcia, a Cincinnati Children's Hospital trauma surgeon, got fed up with seeing gun-shot children on his operating table.  He pledged to a mother who lost her child that he would lead an effort to stop the urban violence in Cincinnati. One result of his efforts is a community project called CoreChange.  I'm involved with one of the CoreChange project teams, called Strengths-Based Cincinnati. Our workgroup has been meeting every few weeks for the past ten months, looking at ways to identify strengths and put them into play, instead of wallowing in the negative energy that surrounds us.

One tool that many of us like is called the VIA Character Strengths survey. It's a positive psychology profile of personal characteristics that make people successful. I am not usually a fan of new-age style pop psych parlor games, but this one makes some sense. It offers a way past negativity, and demonstrates that everyone has strengths, even people facing tough circumstances. The VIA Institute says that this survey is the foundation of a positive approach to life.
A strengths- based approach to life:
  • Is honest (acknowledges problems, but doesn't get lost in them);
  • Is positive (focuses on what is best and good);
  • Is empowering (encourages and advances the individual);
  • Is energizing (uplifts and fuels the person);
  • Is connecting (brings the person closer to others, aiding in mutual connection).
The VIA process starts with an online survey. It takes a little under half an hour for most people, so the online system has you register so you can save your work. When you're done, you can pay for a fancy analysis or choose a free version of the results. The free version was what I chose. Take a look at your top five character strengths, and have a chat about them.

How do your top five character strengths play out in your life?

What can you do that takes advantage of your strengths?

Start the VIA Strengths survey here. .

Learn more about CoreChange.

Dec 21, 2012

What I am doing to respond to Sandy Hook

When Pete Earley asked what we were doing to respond to Sandy Hook, this is what I wrote.
Over the course of the past week, I have written several blog posts about preventing violence of this kind on my blog http://redesigningmentalillnes.... I usually write about mental health recovery, but I know a lot about the connection between mental health and violence. I have designed curricula for NAMI and I have taught crisis de-escalation in courts and jails in Ohio and Kentucky. I have been writing about research connecting violence and mental illness for quite a while. I don't subscribe to the views of either of the policy camps. The TAC offers bad policy, the mental health community wants anti-stigma more than they want to express precision about risk.

There is a realistic way to approach this. The key is that these very hard incidents look just like suicides as they roll out. You don't have to have a "by the book" case of diagnosable whatever in order to have a breakdown or become suicidal. The DSM is just a catalog, after all, and even psychiatric pros will change their mind and argue about what kind of disorder is what. For ordinary people who are not clinicians, the kind of trouble a person has is not material. It's the pattern of the breakdown in thinking that matters, and this can be interrupted. People interrupt suicides every day.A tiny fragment of these people in trouble end up attacking others.

We can interrupt these incidents if ordinary people were better at spotting suicide risk, and learned to have a serious talk or even a simple four-question script. I wrote about the parallels between the Portland shooter and Wade Page, the Sikh Temple shooter one week ago, and laid out the crisis/suicide prevention technique I published in my book Defying  Mental Illness.


A final note: In the NY Times yesterday there was an article about suicide bombers and rampage killers. Adam Lankford, an academic researcher has a book coming out connecting both with motivation to suicide. The article's author and I both agree that the clues and motivations of potential suicide risk are often common denominator in murder-suicides, and ordinary people really do have the best opportunity to prevent all this senseless death.

Dec 19, 2012

Holiday reading for a kinder, braver world

Yes we need gun control and better mental health and all that. But won't we also benefit from a kinder, braver world?

Lady Gaga's Born This Way Foundation has teamed up with Harvard University and the John D. & Catherine T. MacArthur Foundation on a series of research papers to help ordinary people in America grab hold of the future, defeat meanness and bullying, and make kindness stick. There are papers about the role of youth organizations like 4H Clubs and Girl Scouts, and what young people can do to create emotionally healthy schools.

Follow the link. Read the research. Your book report is due when school starts up in January,

The Kinder & Braver World Project: Research Series – Eight Papers on The Role of Youth Organizations and Youth Movements for Social Change

Dec 18, 2012

Frightened moms at the instant before the trigger

Yesterday I met a mom who was frightened of what her grown-up kid might do. The kid's life focused on violent video games. Terrible mood swings. Using drugs. Talking about getting a gun. She told us she tried to get her son to treatment, but he wouldn’t go. We went through a checklist of places she might call. We are doing what we can to help, but what she really needs is a concierge or a companion, because the prospect of presenting a nightmare to another indifferent gatekeeper in a busted-up partially-funded mental health treatment system was overwhelming.

Women in tough situations like this are coming out of the closet all over America.

It is our duty to help these women. When you think about it, the people we must actually rely on for our safety are those who know and love people at high risk. They receive the first trouble signals, many times well in advance of tragedy. Public officials, health workers and law enforcement show up much later. They must receive a call or see someone being hurt.

Frightened moms exist inside and outside the world of mental illness. We can help these women if we put our minds to it. The violence on our streets is not some baffling weird mystery ordinary people can’t grapple with. Criminologists and violence prevention experts already know the patterns to violence that our society must confront.

First, there is the mental model of the trigger man. Does he consider himself to be violent? Does he express himself violently? The violent identity can even be fictional. We have seen many people put on fantasy roles plucked from their larger culture.

Then there is the action pattern of the violent incident.

Researchers who study violent prison inmates have identified three possible developments that determine whether or not a violent actor follows through to commit a violent criminal act. The first is a kind of tunnel vision around a violent interpretation of a situation, where violence becomes the path to be taken. The second is restraining judgment, an escape from the tunnel vision, that lets the perpetrator redefine the situation and decide he should not act violently. For example, a witness may show up, or the person thinks he will get caught, or the person thinks that the violent act is just not worth it. The third element is called overriding judgment, when the person who decided not to use violence returns to his original plan and uses violence anyway because the victim’s conduct or attitude was found to be intolerable.

The same action pattern happens in suicides. People develop tunnel vision. They see no way out but suicide. But they usually remain persuadable. Someone can persuade them not to act. Yet the person is still impulsive. If the person is not brought to safety and kept under observation he may still act impulsively and harm himself.

Risk of suicide and risk of violence both connect with faulty thinking. As thinking deteriorates, risk skyrockets. Bad outcomes become more likely if people get firmly stuck in tunnel vision.  People with troubled thinking are more likely to commit to bad plans. They are less likely to generate alternative ways out of trouble. They have more difficulty processing advice offered by others. They are more likely to act impulsively, even if they retain the capacity to hesitate or reconsider. They have hair triggers.

The reason most of us don’t harm each other is a basic human taboo against hurting people. We don't have violent identities. Whether genetic or cultural, people are averse to seriously harming others, let alone themselves. Soldiers must be specially trained to shoot and kill people. If they don’t practice until shooting becomes instinctive, they need to be urged by officers to pull the trigger even in the heat of battle. (Violent video games are a substitute for all of this.) Pulling the trigger is the kind of threshold that most of humanity never crosses.

Where does gun control fit in?

Guns are part of the environment. If you think of violence as a disease, then guns are the pathogen that must be eliminated. We wiped out polio and smallpox this way. But gun control isn't a complete solution to violence. We have plenty of other lethal instruments lying about. Wiping out polio did not wipe out all sickness, but our world is better for it.

Grossman, D. (2009). On Killing: The Psychological Cost of Learning to Kill in War and Society. New York: Little, Brown and Co.

Rhodes, R. (2000). Why They Kill: The Discoveries of a Maverick Criminologist. New York: Vintage.

Dec 17, 2012

Political correctness in the mental health community is killing people

Those of us who work around mental health, and particularly those of us in the recovery community, must stop whistling in the wind about risk of violence.

The one thing I trust on the Treatment Advocacy Center website is the list of murders committed by people with mental illness. Whatever we may believe about the TAC’s proposed response to this issue, it is time for the mental health recovery community to acknowledge that the list is there, and that dozens of names from shopping malls and schools were added to the list last week.

Yes, I know that people with mental illness are much more likely to be victims, not perpetrators of violence. Yes, I know that it’s important not to fuel stigma. So what. Anti-stigma’s political correctness is murder blindness. It is not compatible with anybody’s safety.

Violence denial does its own damage. It undermines the credibility of the recovery movement. It threatens the very notion of people with mental illness living in regular neighborhoods. It brings out today’s version of peasants with pitchforks, the NIMBY people who agitate against safe housing in our communities.

Recovery involves more than feeling vaguely better about our lives. As we reconstruct our lives, we must confront our real risks, including risk of violence.

I believe that the mental health recovery movement has a responsibility to build the public’s capacity to understand the violence in our society. After all, we are the mad. We own the stories of our lives, including our first-hand experience of the process of breaking down. What lessons can we teach about what it takes to interrupt our path when we are at our worst?

Messaging that gets violence right

It does not take much to get the connection between recovery and risk of violence right. Here’s what I write about recovery in my book Defying Mental Illness.
Recovery is a process of building a person's capacity, empowering the person to overcome the effects of the illness. Every person has a range of talents and abilities, a variety of vulnerabilities, a certain capacity to withstand stress, and a certain risk of causing harm when something goes wrong.
Ask four questions to help build recovery.
-- What helps you make the most of your talents?
-- How can you reduce the areas where you are vulnerable?
-- How can you improve your ability to cope with stress?
-- How can you deal with the risk of something going wrong?
The answers will inform critical choices about treatment, medication, overall health, career, housing, and family relationships.
Here’s another excerpt about crisis and violence.
We usually encounter two types of violence in civilian life: instrumental violence and expressive violence. Instrumental violence is used to gain control over others. This is the violence of robbery and terrorism. Instrumental violence that is fueled by delusional thinking can be as well planned as a bank heist. The other type of violence, expressive violence, is the failure of self-control. People break down and strike out. Anger and frustration builds up to a violent outburst. For people with mental illness, handling the internally generated background noise of their symptoms is difficult enough. Stress and conflict make the internal noise level worse. The "fight or flight" response kicks in. But people usually do control their behavior, even at this point.
Most people with mental illness never become violent. People with severe mental illness but no substance abuse and no prior violence have a very low probability of becoming violent. But risk factors add up. The risk of violence increases if the person has more than one psychiatric disorder. The higher the number of co-occurring psychiatric disorders, the greater the risk of violence. The combination of substance abuse and major mental illness is more volatile. Another key predictor of future violence is past violence. Risk skyrockets after someone commits their first act of violence. For example, nearly a third of people with schizophrenia also abuse alcohol or drugs, and are, statistically speaking, twice as likely as the average person to become violent. If such a person commits a violent act, their likelihood of future violence doubles yet again.
Dangerousness involves reckoning with four factors: magnitude, likelihood, imminence, and frequency. Courts weigh these factors to determine if the facts justify involuntary treatment…
In community settings, people with paranoid delusions are more violent than people in other mental illness categories. Their violence is well-planned, aligned with their delusion, and aimed at individuals or institutions. These individuals are likely to commit the most serious crimes because they can gain access to weapons, stay relatively well-connected to reality, and maintain an ability to plan. There are many other patterns of violence connected to mental illness symptoms. People with depression can react to despair by striking out at other people. Parents may kill their children prior to a suicide, especially mothers of young children. Because everyone's experience of mental illness is so different, it is entirely appropriate to ask treatment providers what risk patterns to look out for. Everyone has a stake in safety. Talking about risk does not make violence happen.
Effective long-term crisis prevention for most people with mental illness means controlling the internal noise level by managing symptoms, plus controlling the stress factors within the environment, plus building self-management skills. As the person builds impulse control and self-manages symptoms, the risk of violent action goes down.

Dec 15, 2012

Coping with a violent child

Note I wrote this post the day before the Newtown CT massacre. I know families who live with the daily threat of violence from children they love. The answer to Newtown lives in the home life of the shooter. This post is about what parents of violent kids go through.

Here's an episode of The Coffee Klatch on Blogtalk radio, a great interview revolving around a family trying to do the right thing for their daughter who they truly love, but who is dangerously violent.

Listen to internet radio with The Coffee Klatch on Blog Talk Radio

The family at the center of the episode is in the middle of it, fighting with school systems, mental health agencies and health insurers to get the care they need.

The episode raised compelling questions many families must reckon with.

 -- Should parents focus on helping their child, or take steps for their own health and resiliency?

-- What if the local schools can't afford to provide care your child needs?

-- What does it take to change a troubled child's life course?

Dec 13, 2012

Mass murder is the new flavor of American suicide

It’s time to add mass murder to the annual “means of suicide” statistics list. There’s more collateral damage when compared to hanging, bridge-jumping, self-inflicted gunshot wound, overdose, poison and wrist-slicing, and so much drama in the act itself, you don’t even need to leave a note.

The only way to stop these murders is for the general public to step up and learn to prevent suicides.

As these incidents are developing, clues and hints of distress and trouble accumulate around a person. We see problems related to how the person is thinking, failure to succeed at work or school, trouble in life, loss of a girlfriend, or other experiences of  shame and guilt. We also notice expressions of  hurt or resentment. When a critical point is reached (and sometimes after surprisingly careful planning) the person takes action. It is at the action stage that suicides and violent attacks diverge. An attacker strikes out against an institution, person or group, or even against random people. The action is a statement.

We are learning that the Portland mall shooter Jacob Tyler Roberts had a life that lately reeked of failure, depression, fantasy, drinking and more. He quit his job at a sandwich shop,  and sold all of his belongings. He gave up his dream of becoming a firefighter. He broke up with his girlfriend. He dropped out of community college. He made up a fantasy plan about buying the shop where he worked. He lied about inheriting a large sum of money.  He was supposed to move to Hawaii but didn’t, saying he missed his flight because he got drunk (if there actually was a flight). He had a Facebook cover photo that said “Cancelled.” He wrote  on his Facebook wall: "I may be young but I have lived one crazy life so far." Once easy-going and sociable, he dropped out of sight this past year. His phone was disconnected. He was evicted from his apartment in July. His Oregon driver’s license was suspended. His commercial driver’s license was suspended. He wrote that he was an adrenaline junkie who enjoyed shooting.

There are parallels between Roberts and the Sikh Temple shooter Wade Page, whose final hate drama episode took place just up the street from the restaurant where his ex-girlfriend worked. 

Page’s military career ended in 1998 when he refused treatment for his drinking. By 2000, then age 29, Page’s beliefs about an impending holy war were fixed. In 2000, Page sold everything he owned and went on a cross country trip attending festivals and shows. In 2001, he couldn’t hold a regular job because he drank so heavily that he would pass out and miss work the next day.  In 2003, Page was having trouble paying his bills, irritating his friends and evidently wearing out his welcome. He moved back to Fayetteville, where he worked at a Harley-Davidson dealership for a year and a half. The dealership fired Page because he refused to obey orders from female co-workers. According to his former boss, Page showed a volatile side when women tried to tell him what to do. He worked as a truck driver from 2006 – 2010. He was fired after a DUI offense. His home was foreclosed on in January 2011. He moved to Milwaukee in 2011, where he moved in with a girlfriend. He was hired as a temporary night shift worker in a local factory in February. Page and his girlfriend broke up in June 2012. Page stopped showing up for his job in mid-July. His landlord said he owed back rent when the attack happened in August, about a block from where Page’s ex-girlfriend worked..

What everyone can do to prevent attack-suicides

In most of these situations the only possible intervention is below the level of our formal systems. 

Prevention is the responsibility of family, friends, co-workers and neighbors. Even if reported, emergency responders can't act forcefully if the risk is not immediate and serious. Sometimes the police or a crisis team might be able to make a safety check visit to a person's home.

The best thing anyone can do is to support their friend. This helps prevent feeling isolated and helps build resiliency. You are unlikely to ever know if the steps you take to support a friend have prevented a suicide or interrupted a developing course of violence. You want the person to become more resilient and successful, so that the outcome is positive.

Try to have a brief chat in a public place but out of earshot of other people. Ask the following questions one at a time, in order. Practice the questions out loud. Yes, this is awkward. You can use your own words, but follow the pattern. Listen to the person's answer. People benefit simply by knowing they have been heard.

-- What have you accomplished since the last time we talked?
-- What are you facing?
-- Who are your allies?
-- What is your plan?

As you listen, be on the lookout for suicide risk factors. These include prior violence, substance abuse, a failure of addiction or mental health treatment, difficulty verbally expressing feelings, stress, extreme discouragement or recent shameful loss, no ability to make effective plans, trouble relating to other people's feelings, the onset of schizophrenia or another major mental illness, and lack of sources of support.

If you start to feel worried, offer to connect your friend to a more formal source of help. You may have the single most important opportunity to help your friend. If you detect tunnel vision and a sense of diminishing options, or the person talks about suicide, or expresses a lack of hope, ask the person directly about thoughts of suicide. Suicide is much more likely than violence directed against other people. Ask directly using these words: "Are you thinking about killing yourself?"

If you sense that the person is becoming suicidal, stay with the person. Try to persuade them to seek help from their doctor or visit an emergency room. Offer to help them get in contact with a crisis hotline by calling 1-800-273-8255 or dialing 911.

Effective suicide prevention training is available online through the QPR Institute at and from many community groups.


Clackamas Town Center shooting: Friends say it’s hard to imagine Jacob Roberts as a killer. (n.d.). The Oregonian - Retrieved December 13, 2012, from

Elias, M. (2012). Sikh Temple Killer Wade Michael Page Was Radicalized by Army Base’s “Thriving Neo-Nazi Underworld”. AlterNet. Retrieved from

Ex-friend says temple shooter Wade Michael Page was a “loner”. (2012). Retrieved December 6, 2012, from

Lohr, D., & Lohr, D. (2012). Wade Michael Page Timeline: Key Dates To Sikh Temple Shooter Investigation. Huffington Post. Retrieved December 6, 2012, from

Motives of Portland mall gunman Jacob Tyler Roberts remain a mystery to family, friends, police. (n.d.). NY Daily News. Retrieved December 13, 2012, from

Oregon mall shooting suspect not the “violent type”: ex-girlfriend. (n.d.). Retrieved December 13, 2012, from,0,6711130.story

Sikh Temple Killer Wade Michael Page Radicalized in Army | Southern Poverty Law Center. (2012). Retrieved December 6, 2012, from

The Ballad of Wade Michael Page. (2012). Retrieved December 6, 2012, from

US Sikh temple shooter was a white supremacist. (2012). Retrieved December 6, 2012, from

Wade Michael Page: Excessive drinking cost Sikh temple shooter his military career, civilian job. (2012). Washington Post. Retrieved December 6, 2012, from

What brought Wade Michael Page to Milwaukee? (2012). Retrieved December 6, 2012, from

Dec 12, 2012

Defending Recovery

There's a report floating around the internet these days claiming that "recovery" thinking threatens the health of people with mental illness. The report claims that the sickest among us have no capacity to recover, and if  you don't fully subscribe to the biopsychosocial/medical model of mental illness, you are depriving people of needed access to medical treatment. It's a lock-up or medicate piece along the lines of what you might read from the Treatment Advocacy Center. Pete Early reacts to it here. I wrote a comment on that post, and another to an earlier Huffington Post blog by Marvin Ross. 

The author of this report, Lembi Buchanan, deserves praise for her activism, which is grounded in support of her husband's survival from a very difficult experience of mental illness. She told Marvin Ross that her husband of 40 years would not be alive today if it hadn't been for involuntary hospitalization, medication and treatment on occasions when he has had psychotic episodes. She said that her husband is grateful for having been saved from suicide and for the support that has kept  him in good health.

What I like about Mrs. Buchanan's report is the opportunity it provides to review what we believe about recovery and the role of treatment in extremely difficult circumstances. The theoretical limits of recovery is an issue worth exploring.  I know that some people are not comfortable with the concept -- and even I have some trouble with it, which I have written about before.  What I don't like about Mrs. Buchanan's report is the way she mischaracterizes today's recovery movement by claiming that today's recovery-oriented groups and today's anti-psychiatry groups are essentially the same.

Recovery may have started out connected with anti-psychiatry, but it's a mistake to jam the two concepts together today.

Recovery literature is less than fifty years old. Authors like Judi Chamberlin, who created the language of the recovery movement, were reacting against psychiatric hospitals that operated as very coercive "total institutions."  Thomas Szasz was inventing antipsychiatry at roughly the same time. Chamberlin quoted Szasz, and even E. Fuller Torrey (who was a Szasz follower at the time) in her 1978 book On Our Own.

Recovery and anti-psychiatry are separate concepts these days. Psychiatrists, healthcare administrators and insurance companies have all signed off on recovery, with recovery being the notion that people can get better, decide what's important for them, and assert control of their lives. Recovery even has a SAMHSA-approved cousin, whose name is shared decision-making. At least on paper it seems the bad old days of one-sided, white-coated, doctor-driven psychiatry are gone. Even inside hospitals, care is meant to be person-centered.  In many hospitals today, few decisions are made without the patient's buy-in, participation or consent -- or a court order. 

Sadly, people with mental health conditions still get to the point where they're not safe. Most of the time, these are not people fully engaged in recovery. People pursuing recovery, with or without medication, usually know what they must do when they are getting into trouble. The people I worry about are those the system fails to help when they show up in emergency rooms asking for help, and those the system fails to detect or engage, the people who have disordered lives, clusters of sub-clinical trouble symptoms, who never get diagnosed until they are drugged or drunk, suicidal or psychotic, out of control, blatantly unsafe and possibly a threat. Society needs to be able to respond appropriately. Jails are no help, so we need hospitals, and community-based solutions.

As I worked through my own recovery, and later, when I ran a substance abuse treatment program that supported people who did not respond to AA, I came to realize that diagnosis and labels essentially did not matter in the lives of non-clinicians. What matters in recovery is engaging in the struggle, finding a path for moving forward. An hour or two of training lets anyone spot signs of trouble in people's lives. The real work follows, connecting people with a clinician who can do a real work-up and help create a treatment and recovery path that works for that individual.

So here's where I have ended up. Pro-recovery, pro-science, pro-therapy, pro-psychiatry, pro-choice, pro-wellness, and anti-coercion (to a point). Neutral on meds.  Unfortunately, some people need treatment, imperfect as it may be, at times when they don't want it. The anti-psychiatry folks are the experts on how offensive and distasteful involuntary treatment is. It would be great to have workable, effective alternatives that can be funded with healthcare dollars, but right now, we have what we have, and it's certainly not perfect either.

But recovery is nobody's threat.

Dec 1, 2012

Viewing insanity from outer space

Think about how mental illness plays out in our world. How can ordinary people affect its trajectory?

Start by thinking small.

We have some choices in our own lives. A better diet. More sleep. More exercise. Seeing the doctor. You already have the whole list.

As we move through our days, choices show up in our homes, and workplaces, and the other places of our daily lives. Can we see and hear the clues and cries for help around us? Do we know the smallest thing that we do on the spot? Do we know how to have a chat when it matters?

As people make small choices, bigger things emerge.

And in today’s world, the things we do, the actions that emerge, all generate data.

People have always known that if you find a different vantage point, you can see different things. From the top of the hill you can see a whole battle play out. If you have binoculars, you can zoom in and pay attention where it counts.

Today’s binocular lenses are made to detect data.

In fact, today’s technology gives us practically infinite zoom focus. Ordinary people, often for free, can access data from a health care landscape that ranges from the invisible micro-wavelengths of the brain, to the microscopic ecology of our bloodstreams, the intimate details of electronic health records, to the aggregate data of our census tract, our social crowd, our church group, our zip code, our region or political entity, or for that matter, all of the earth.

We can choose a data lens that lets us view insanity from space.

Healthcare experts know this. Health care used to take place in doctor’s offices or hospitals. The economics of health care worked themselves out through individual transactions and pricing by the visit or procedure. 

Our new data lenses are catalyzing the development of new economic models for health care.

These days, in fact, healthcare no longer thinks of itself as an industry. Today, healthcare is an eco-system.

Here in Cincinnati – and maybe in your town – healthcare plays out in networks that collaborate as well as compete. Transactions that happen within these networks tend to be more expensive and reimbursable within traditional brick-and-mortar medical spaces, like hospitals and doctor offices. But now you see agents of these networks venturing farther from traditional centers. Is there a parish nurse at your church? Does your pharmacist pack a stethoscope?

There might be less reimbursement away from the center, but healthcare is investing in reaching you where you are most likely to go. That’s because supercharged data lenses have connected with the economics of health care, and health care networks are now being paid for the health status of whole populations. If you doubt this, type “accountable care organization” into an internet search box.

Nov 17, 2012

Do-it-yourself brain repair is happening right now

What’s in humanity’s mental health toolkit?

How are ordinary folks helping people with mental illness symptoms make progress in their lives?

The one thing I know for sure is that the list I came up with is not long enough.
  • Accountability
  • Community
  • Companionship
  • Conversation
  • Courage
  • Curiosity
  • Education
  • Emotional connection
  • Employment
  • Family life
  • Friendship
  • Habit
  • Hugs
  • Journaling
  • Kindness
  • Labor
  • Love
  • Medicine
  • Mentalizing
  • Mother’s love
  • Nutrition
  • Observation
  • Physical activity
  • Planning
  • Prayer
  • Reading
  • Reflection
  • Religion
  • Responsibility
  • Ritual
  • Scaffolding
  • Scientific method
  • Scripts
  • Sex
  • Shame resilience
  • Social interaction
  • Spirituality
  • Storytelling
  • Sympathy
  • Teaching
  • Tenacity

Nov 12, 2012

Recalled to Life

Social inclusion is about rejoining all of society, not just your club of outcasts.

-- If everyone around you shares some defining characteristic, you are living in a ghetto and can be relocated at will.

-- Your weekly activity group does not get you there, no matter how great you get at performing the activity.

-- Your inspiring slogan does not help. People who don't need the slogan just pity you.

-- You are not a group of special people. You have been forced to hang out together by a system that thinks you need diversion. The system will withdraw resources once it sees you are successful.

-- If you are running a program for a special population, you should reconsider what you are doing.

The sense of exclusion, of life as an outcast, as someone less valued, is spread unthinkingly but felt intimately. Exclusion of the defective and fear of the alien are evolutionary adaptations. They are built in to people. So is the notion of dominance. People in charge inevitably dominate the folks who are at their mercy. When people in charge are denied resources, the people who are weakest suffer. Showing that the defining characteristic is permanent just reinforces the difference. Tagging more people with your outcast label seems beside the point.

So what works to fix this?

The only way social change has ever been proven to work is when life in our communities changes. It takes decades, sometimes longer. How long did it take for women to obtain the right to vote? For slavery to end? For civil rights? For marriage equality to emerge anywhere? Remember when mixed marriages were a scandal? Remember when selling condoms, let alone abortion, was illegal?

Tough social issues involve struggles, long tails, and aftermaths, and leftover partisans, and sometimes counterrevolutionaries. There's an issue spectrum that ranges from disapproval to recommendable. Issues resolve when people start acting like the formerly scandalous thing is just normal, or eccentric, or at least tolerable.

In the world of mental illness, we must have our struggles too. Right now there are rhetorical wars over compulsory treatment, the number of hospital beds we need, and over faith in pharma. I am okay with this level of conflict. Every side has its points.

But we do need to adjust what we are doing in the fight for social inclusion.

-- We must start by including ourselves. This means showing up at work and at other places that are not defined by disability. Divert people from system-driven isolation. If you are renting space for your clubhouse, give it up. Borrow a conference room at a library, church or community hospital once a week. Spend the rent money on coffee at the local diner, music lessons and on YMCA memberships. If you are looking for a social enterprise, start a conference center, a web design firm, or your own restaurant, and aim for top-of-the-line. If you want empowerment, have people join their political ward club. You can deliver support, but let your people go.

-- Disclosure is irrelevant. Nobody cares about your diagnosis. Let people get to know you. Get over your embarrassment. Everybody is hiding something. By the way, the stories we tell about ourselves are always approximations. Everybody just makes them up.

-- Confidentiality is a barrier. We say it is protecting us, but it also keeps us apart. It's okay to have barriers like these, but we need to put gates where they're needed.

-- Realize where you can't win. You have to be willing to swing with science, with capitalism, and with the two-party system. So what if scientists say the thing folks have is usually genetic. They don't know what happened to you.

-- Start talking in terms of universals. We all have our problems. Everyone has skills and talents to contribute. Everyone needs to take a break or regroup. Everyone needs a chance to socialize.

-- Embrace the sensibilities of the nonprofessional. True reform in mental health has always been instigated by non-professionals. Dorothea Dix was a housewife who expected the asylums she advocated for to be free of crushing restraints. Clifford W. Beers was a businessman who exposed cruelties in psychiatric care. In the 1940's, conscientious objectors forced to work as psychiatric orderlies took photos that revealed the scandals of the modern Bedlam. Judy Chamberlin experienced coercive 20th Century institutionalization. NAMI's founders were parents who wanted a better life for their children. Professionals speak in terms of dosages and treatment plans. Non-professionals talk about cruelty and justice.

Above all, we need narratives that work and build power. Recovery works like the parable of the prodigal son. We all have our struggles. We rebuild with our strengths and the help of our allies. We love our sisters even when they need some support. We want people to be different. We want people to get better. We are all alike. Everyone deserves to be safe. We want to find each other and make our way in the world.

We must own our powerful stories of redemption, of rescue, of being recalled to life -- and show up everywhere..

Nov 9, 2012


What can we do to counter the "medical horror" component of mental illness stigma? We say that people with symptoms need treatment, but we know that is not completely true.

People fear treatment, and for good reason.

Even SAMHSA publications recognize that the treatments currently available are not fully satisfactory. Here's a quote from a May 2012 SAMHSA "Recovery to Practice" article.
First, the treatments that are currently available are extremely limited in their effectiveness in treating serious mental health and substance use conditions. While some treatments may be effective for many people in reducing the more active aspects of these conditions (such as in reducing psychiatric symptoms or substance use), they typically do not address the more disabling elements (such as neurocognitive difficulties, deeply entrenched patterns of behavior, and social and interpersonal contexts that impede, rather than facilitate, improvement). Should medications be developed that were as effective in treating mental illness and substance use as antibiotics have been in treating certain infections, then we might not find it necessary to change the ways in which we plan and deliver care. Such a day, however, seems far off, should it be achievable at all.

Second, the vast majority of the challenges people face in recovery occur outside of, and beyond the scope of, traditional health care settings such as hospitals, clinics, day programs, or intensive outpatient programs. These challenges occur, and must be dealt with, within the context of the person's everyday life in the community.
If people have reason to believe that what the medical system has to offer are medications with long lists of side effects that dope you up, or electroshock jolts to the brain, or hospitals that steal your freedom, is that stigma or is that the truth?

I am a firm believer in mental illness recovery, but the story I see playing out is not fundamentally a victory of medical science. Recovery happens with the kindness of ordinary people and the support of family and friends. Medication and other treatment may help, but the essence of recovery is a steady focus on making the most of one's talents and capacities, and committing to the struggle of regaining one's life.

Nov 4, 2012

That hug from your mom is an evidence-based practice

Seriously, when things got difficult for you as a child, that hug, the attentiveness and comfort you received from your mother or another caregiver helped create the success you have today. This is one of the lessons from Paul Tough’s new book How Children Succeed: Grit, Curiosity and the Hidden Power Of Character, a book that updates our understanding of the dynamics of creating successful people.

Those hugs helped calibrate your developing stress response system. The body’s stress response system works best in short bursts, with long rests in between. Too much activation and the stress reaction becomes self-reinforcing,  inefficient, always set to trigger. Think of a car with an alarm so sensitive that you can’t walk past without starting it blasting.

Stress hormones put additional wear and tear on the body, affecting infant growth patterns and eventual life functioning. A mother's fast response to an infant’s experience of stress allows the stress reaction system to turn off when it needs to. And, as the child learns that his mother will respond to help him overcome his stress, that understanding produces what’s called “secure attachment,”  a close emotional bond between the infant and his mother or other caregiver. Large data sets accumulated over the course of decades show that some sixty percent of US children experience secure attachment, which connects with greater resilience throughout life. Careful analysis of decades of data reveals that stress and resilience are the common hidden factors within the many studies that show children in poverty have less satisfactory life outcomes.

Exposure to trauma, so-called “adverse childhood events” (which happens more frequently to children experiencing poverty) also impacts brain function. The child’s stress system gets overloaded through the same mechanism that causes post-traumatic stress disorder.  Anxiety and depression are the emotional impacts. Decreased executive function (the ability to deal with confusing and unpredictable situations) is the cognitive impact.

People need both emotional and cognitive capacities to function effectively. According to How Children Succeed, kindergarten teachers say the most difficult children to teach are those who can't manage their tempers or control their emotions. According to Tough, “When you’re overwhelmed by uncontrollable impulses and distracted by negative feelings, it’s hard to learn the alphabet.”

Researchers have found that secure attachment is a key precursor of life success. Statistically speaking, it accounts for those children raised in poverty who do succeed, and those children in so-called “good homes” who don’t. Stressed-out moms living in difficult circumstances are more likely to get overwhelmed, less likely to respond as attentively or effectively to their own children. It’s no wonder that kids in families who have experienced poverty over the course of generations face particularly difficult challenges.

From a public policy point of view, if we want more people to succeed, what needs to happen?

One strategy being used across the US is parenting support for new mothers, usually delivered during brief home visits by public health workers. New mothers are learning what works, and building strong attachment with their children.

Another set of strategies aimed at young families works on reducing the number of adverse life events children experience. We have a series of publicly funded programs to reduce children’s exposure to violence.

Other strategies apply later in the life course, in child care, youth programs and schools. Here, the work is always harder. The most effective strategies build "noncognitive skills" together with cognitive skills. Many of the educators highlighted in How Children Succeed refer to these "noncognitive skills" as "character strengths." Educators build curricula around characteristics like grit, integrity, and perseverence --markers of capacity to complete a task, postpone a reward, find one's way through difficulty, and stick with a plan.

The problem with the character strengths label is that it can end up sounding vague, preachy and political. That’s the criticism leveled at some of the charter schools that favor a character strengths approach. Nonetheless, programs with this focus do show improved outcomes for children who otherwise face significant life challenges.

I've seen other methods aimed at building these same capacities that use more neutral terminology. One example is the so-called "developmental asset" strategy. Developmental assets are things children have in their lives that are associated with better life outcomes. The research behind them, conducted by the Search Institute, supports the work of the YMCA, the Boys and Girls Club, and 4H Clubs. Equally well-researched, developmental assets have the advantage of being somewhat more concrete. Attending church, doing homework, playing a musical instrument, having positive friends are all developmental assets, and there are thirty-six more as well. Most of them can be supported by the efforts of community members. There's a lot of overlap wth character, so the language of character strengths is compatible, and gives people multiple ways of explaining why taking your time and following through is important.

Another set of strategies comes from Ruby K. Payne, whose work focuses on the effects of generational poverty on child achievement. The strategy she recommends encourages students to generate several alternatives before taking action. She also recommends using relationships to motivate children to do better.

For me, the lesson is that it's ordinary life, and interventions based on kindness, relationships and stability that really create success. And here’s another lesson: The solutions for our children’s most difficult challenges are, for the most part, already known. They are variations on themes that everyone can understand.

Nov 1, 2012

Colleges refuse to learn Virginia Tech's mental health lessons

Five years after the 2007 Virginia Tech shootings, colleges still haven't learned to help students with mental illness.

Nearly two out of three college students who encounter mental health problems end up withdrawing from school, according to a new NAMI survey. Read NAMI's press release here.

According to the survey, students in trouble don't use counseling services, even if they are available. Disability services offices don't help them. Worst of all, faculty members still have not been trained to recognize or respond properly to mental health issues.

Apart from the violent consequences, and the routine academic failure of students who might succeed if they were accommodated, we are now sending thousands of veterans, many with post-traumatic stress disorder, to every college in the US, doomed to fail because campuses won't step up.

This is an outrage, a display of deliberate ignorance -- but there's a practical solution.

It takes a couple of hours to do basic mental health training, maybe half a day if you include suicide prevention. Every college campus has someone qualified to teach Psychology 101, plus someone who runs campus security.

If these two people can't put together an effective training program for your campus, call me.

Oct 22, 2012

Mental Health and Social Innovation in the UK

Every once in a while I spot someone who is as interested as I am in building social capacity around people with mental illness. Here's a very cool podcast featuring an interview with Mark Brown, mental health campaigner and editor of "One in Four" magazine. *The video camera ran out of tape during this recording, hence the still-frame from 36.24 to 47.12

Oct 19, 2012

Life Beyond Recovery - Comments on Flourishing

A couple of months ago I suggested that "recovery" wasn't good enough, and that people could accomplish more than that - they can "flourish." You can read the original post here. I've had a lot of feedback about this, and thought I would present some of the comments from a LinkedIn discussion on the topic.

I am becoming more and more convinced that the normalization of mental illness and the elimination of stigma are possible only if we stress people's potential instead of their sickness. What do you tell an adolescent about their prospects in life -- that they will always be diseased? That they have a limited sort of hope for recovery?

Everyone wants to flourish, and I think that people can get there once they gain control of their lives.


Recovery is great but flourish sounds healthy, happy, challenged, and where we all want to be. It normalizes and contributes to one feeling as a working part of a whole.
While constantly trying to improve ("recover"), I flourish. I am now capable of being passionate about life, people, and my career.
I love the idea. I think a challenge is the issue of funding sources that want and push for "recovery" or "cure" because we still push the medical model in the diagnosis and treatment of Mental illness. It could be a pardigm shift for the field.
The term recovery has only positive connections to living life well in my humble opinion. Fortunately, I have a great psychiatrist and my experiences were mostly positive in my recovery. Giving the medical model its due in no way precludes the idea that people can flourish. 
People with mental illnesses have been flourishing for years now. Only most of us live in hiding because of the stigma. 
Flourishing is what you do when you choose recovery. Years ago Martin Seligman wrote a book titled Flourish about this concept. It expounds further along in his concept of Authentic Happiness and well being. 
The word we need to toss out is "mental illness." I too take an assets model approach to life. Focusing on wellness is the most productive use of our time. I always equated recovery with wellness.
I can only offer what I've learned through my son's experience. 'Recovery' itself is misleading to us as schizophrenia is not like the common cold where he could recover or get over it. I like the use of Flourish but I feel it is only in the later stages of managing the illness' symptoms that this can actually be realized. There must be something between intervention, treatment, management of symptoms, and then flourish. That is the goal, to flourish. That is also the process.
As a Certified Peer Support Specialist & self-disclosing prior client of the facility in which I work, I have to say that working with my groups is the most hopeful thing I have ever experienced in the mental health world... where one did not have the option to truly "be themselves", they now can participate in a supportive group of "like minds" in a recovery-oriented, (or for some, symptom management - thus, flourishing-oriented),environment that is "on their level".

Oct 3, 2012

Defying Mental Illness 2013 Edition Now Available

Andrea Schroer and I are pleased to announce the 2013 Edition of Defying Mental Illness: Finding Recovery with Community Resources and Family Support.

This is a major update. We reorganized the material so it is even easier to read -- and added new material on eating disorders, family support, suicide prevention, anti-stigma programs, and violence prevention, plus we updated our sections on Social Security, Medicare and Medicaid.

More importantly, we responded to reader suggestions and included new material that helps churches and community groups do outreach to people with mental illness. We have included a simple script that anyone can use to provide support and screen for trouble. It's just four questions. We think that simple scripts and some very basic training can accomplish for mental illness recovery what AA accomplished for sober recovery. Anyone can use our book to help a friend stay safe and engaged in a recovery process.

Defying Mental Illness is the only book of its kind. It is a one-volume quick reference, plus a resource guide, plus a guidebook to recovery. It works as a basic textbook. Most importantly, Defying Mental Illness is truly strength-based, focused on recovery, and designed to keep families working together to support each other.

The new edition is currently migrating through our distribution channels. It will be available on all e-book platforms and through Amazon, and distributed to libraries and institutions through Baker and Taylor. The distribution process should be complete within about two weeks.

The following direct links work right now.

Defying Mental Illness 2013 Edition on Amazon -- print edition.

Defying Mental Illness 2013 Edition - Kindle Version on Amazon

Defying Mental Illness 2013 edition - All ebook formats on Smashwords - includes Nook, Apple, Kobo, Sony, and PDF versions.

Sep 12, 2012

Ordinary folks and the next big idea for mental health

When expert systems have no capacity to help, ordinary people can pitch in. It can work for mental health the same as for anything else. That's the message I've been trying to convey in this blog for the past few months. It's the same message Vikram Patel has for us in his recent TED talk.

I want to make mental illness accessible to the general public, and give ordinary people something to do about it. There is untapped capacity to deliver results below the level of our formal treatment systems, capacity that can change the whole experience of mental illness in America.

  • People in churches, schools and workplaces can learn what they need to about mental illness, and possibly even pick up a few things to do about it, in a couple of hours, sometimes less. 
  • Nothing prevents the mental health field from popularizing itself, other than its own self-imposed rules and culture. 
  • Ordinary people have always been mental health’s reformers, and they have always used the widest-reaching  popular technology of the day. Clifford W. Beers was cutting-edge. 
  • Another challenge for the mental health field is a culture focused on scarce and shrinking resources. The field has been stuck on doing less with less for decades. Even advocacy groups have chased money that comes with too many strings and interferes with true “consumer protection.” 
I believe the greatest opportunity for improving the lives of people with mental illness lies in building the strengths and capacities of ordinary non-expert people in communities across the US. We need solutions that bring recovery and successful living with mental illness within the skill level of the mass of society. We need to de-emphasize experts and allow people to support each other (as they have indeed been doing, under or above the radar, in every culture, since the dawn of time). 

We need something that delivers broad social impact at low cost or free, exactly what AA did for sober recovery.  That’s the focus of my current work. My book Defying Mental Illness focuses on how to create success instead of having one’s illness, and helps family members support people they love. The Redesigning Mental Illness blog project focuses on systems change efforts and developing skills within communities. I even have a stripped-down mini-support group concept that lets anybody support another’s mental health (or overcome other challenges). 

All my work is consensus based, and strength-based, and designed to bridge the factionalism that has plagued this work.  We need a modest infrastructure that supports broad-based social inclusion initiatives, the only kind of anti-stigma effort that actually works.

Those are my ideas – but I know that others across the US have other ideas, and the capacity to implement them. I support a social innovation model developed by NESTA in the UK called “radical efficiency.” It delivers new solutions that are different and better and lower-cost, not less-for-less or same-for-less. The basic principles of radical efficiency are:

  1. Make true partnership with users the best choice for everyone.
  2. Enable committed, passionate and open-minded leaders to emerge from anywhere.
  3. Start with people’s quality of life not the quality of your service.
  4. Work with the grain and in the spirit of families, friends and neighbors.
  5. Manage risks, don’t just avoid them.
One of the programs identified in NESTA’s report is Mental Health First Aid. I think that community-based, peer-delivered, non-medical brief respite fits in this mold, as do restorative justice programs in homeless shelters, as do many other sorts of diversion and health education initiatives. 

So take a look at Vikram Patel's video. What's your big idea for really changing the experience of mental illness in America?